Dupuytren\'s Disease > Plastic Surgery

Morbus Dupuytren is particularly widespread among northern Europeans, but the therapeutic success-rate often leaves much to be desired. A 50% recurrence-rate after surgery indicates that the disease cannot be treated by surgery alone. This book therefore adopts two parallel approaches: emphasis is firstly placed on the systemic character of morbus Dupuytren in context with other connective tissue diseases by a description of the biochemical and molecular-biological changes in the diseased connective tissues; secondly, a diversified picture of the given anatomical facts serves to explain the employment of the various therapeutic approaches. In addition to the aspects of conservative therapy, a description is given of the current surgical procedures including the complications typical of the same, and accompanied by basic drawings. The book is intended for all those interested in a comprehensive up-to-date survey of morbus Dupuytren, and in instructive information on the established therapeutic concepts. Keywords: anatomy of the palmar faszies, chiroplasty, hand surgery, operation techniques, surgery, therapy, cheiroplasty

Contents: Contents 1. Introduction 2. Dupuytren's contracture - overview of its medical history 3. Epidemiology 3.1. Prevalence of Dupuytren's contracture among Caucasian (white) people 3.2. Incidence of Dupuytren's contracture in Germany 3.3. Age and Dupuytren's contracture 3.4. Sex distribution in Dupuytren's contracture 3.5. Left- or right-handedness in digitopalmar contracture 4. Theories about aetiology and pathogenesis 4.1. Association between trauma and Dupuytren's contracture 4.2. Ectopic fibromatoses 4.2.1. Garrod's knuckle pads 4.2.2. Plantar fibromatosis 4.2.3. Penile fibromatosis 4.3. Cirrhosis of the liver and Dupuytren's contracture 4.4. Alcohol misuse 4.5. Nicotine abuse 4.6. Epilepsy 4.7. Neurogenic hypothesis of Dupuytren's contracture 4.8. Hereditary factors 4.9. Dupuytren's diathesis 4.10. Coincidence of Dupuytren's contracture and disorders of the immune system 4.10.1. Autoimmune disorders 4.10.2. AIDS 4.11. Dupuytren's disease in patients with diabetes 4.12. Vascular disease 4.13. Oxygen radicals and induction of Dupuytren's 5. Basic substance and cells of the extracellular matrix 5.1. The extracellular matrix 5.2.1. Mobile and stationary cells of the extracellular matrix 5.2.2. Fibrous proteins 5.2.2.1. Structural proteins 5.2.2.2. Adhesive proteins 5.2.3. Glucosaminoglycans of the extracellular matrix 5.2.3.1. Structure and function of the glucosaminoglycanes 5.2.3.2. Particularities of hyaluronic acid 5.2.3.3. Chondroitin and its analogues 5.2.3.4. The dermatan group 5.2.4. Fascia and plasma patterns of glycosaminoglycans in Dupuytren's disease 5.2.5. Interactions between collagens, glycosaminoglycans, and fibroblasts 6. Subjective complaints 7. Symptoms of Dupuytren's contracture 8. Course of Dupuytren's contracture 9. Anatomy of the palmar fascia (G M RAYAN) 9.1. Development of the palmar fascia 9.2. Anatomy of the palmar fascia 9.2.1. Ulnar aponeurosis 9.2.2. Radial aponeurosis 9.2.3. Central (palmar) aponeurosis 9.2.3.1. Longitudinal fibres 9.2.3.2. Transverse fibres 9.2.3.3. Vertical fibres 9.2.4. The digitopalmar fascia 9.2.5. The digital fascia 10. Classification 11. Conservative treatments 12. Aim of surgery 13. Surgical indications 13.1. Thoughts on the indication in the nodal and cord stages 13.1.1. The nodule stage 13.1.2. The cord stage 13.1.2.1. Surgical macropathology of the cords 13.1.2.1.1. Pretendinous cord 13.1.2.1.2. Central cord 13.1.2.1.3. Cords of the Ligamentum metacarpale transversum superficiale ("natatory cord") 13.1.2.1.4. Spiral cord 13.1.2.1.5. Lateral cord 13.1.2.2. The digital ligaments 13.1.2.2.1. The retaining ligaments of the extensor apparatus 13.1.2.2.2. The GRAYSON and CLELAND ligaments 13.1.2.3. Longitudinal section of the digitopalmar continuum 13.1.2.4. Horizontal and threedimensional arrangement of the digitopalmar continuum 13.1.2.5. Mechanical strains 14. Choice of surgical method (the classical methods) 14.1.1. Fasciotomy 14.1.2. Needle "fasciectomy" 14.1.3. Segment resection 14.1.4. Partial fasciectomy 14.1.5. Indication for the "open palm technique" 14.1.6. Total fasciectomy 14.1.7. When to use dermatofasciectomy 14.2. Indications for additional measures 14.2.1. Arthrolysis 14.2.2. Arthroplasty 14.2.3. Arthrodesis 14.2.4. Amputation 14.2.5. Continuous elongation technique (TEC) 14.3. Indications for further simultaneous interventions 14.4. Indications in case of relapse 14.4.1. Genuine and false relapse 15. Contraindications 16. Patient education 17. Preparation of surgery 18. Instruments 19. Anaesthesia and positioning 20.1. General observations about skin incisions 20.2. Access points on fingers and palm 20.3. Resection of the diseased Dupuytren's tissue 20.3.1. Fasciotomy 20.3.2 Needle "fasciectomy" 20.3.3. Segment fasciectomy 20.3.4. Partial fasciectomy 20.3.5. The open palm technique 20.3.6. Total fasciectomy 20.3.7. Dermofasciectomy 20.3.8. The continuous elongation technique 20.4. Skin suture 20.4.1. Skin transplants 20.4.2. Homodigital flap grafts 20.4.3. Heterodigital flaps 20.4.4. Free transport of tissues 21. Additional measures to improve manual function 21.1. Contractures of the small digital joints 21.2. Extension methods 21.3. Teno-and arthrolysis 21.4. Corrective osteotomy 21.5. Arthrodeses 21.6. Amputation 22. Postoperative treatment 22.1. Follow up treatment after minimally invasive procedures 22.2. Postoperative management after partial and total fasciectomy 22.3. Specifics of the open palm technique 22.4. Aftercare in cases of transplantation and local flaps 22.5. Aims of physio- and ergotherapy 23. Mistakes, risks, complications 23.1. Haematomas 23.2. Lesions of the vascular nerves 23.3. Necrosis of wound margin/EDGE 23.4. Loss of the transplant 23.5. Flap necrosis 23.6. Dystrophy of reflexes 24. Results 24.1. Functional results and rates of relapse 24.2. Complications depending on surgical method 25. Conclusions 26. Bibliography 27. Acknowledgements 28. Figure legends

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