DUPUYTREN'S C O N T R A C T U R E : RECURRENCE AND EXTENSION

F O L L O W I N G SURGICAL TREATMENT

By STUART GORDON, M.B. From the Department of Surgery, University of Toronto

ONE hundred and twenty hands belonging to seventy-eight patients operated upon for Dupuytren's contracture were examined at periods varying from a few months to twenty-one years post-operatively to determine the frequency of recurrence or extension of the disease. All but three of these patients were operated upon by the writer, using a technique described in 1948. Disease within the area operated upon was regarded as a recurrence : disease beyond the confines of the operative field was considered an extension.

The group was divided into five sub-groups to aid in clarification, namely: A, those showing no evidence of recurrence or extension ; B, those showing recurrence; C, those showing recurrence in one hand only when both hands had been operated upon ; D, those showing extension only ; and E, those showing both recurrence and extension.

By far the largest group was that without recurrence or extension. This comprised forty-six patients and sixty-six hands. Forty-two were males. The youngest patient was 28 years old and the oldest 73, the average being 47. They had had the disease for an average period of 6. 5 years (twenty-seven patients) varying from six months to twenty years. Examination was done on an average of 5.6 years post-operatively (Table I).

i to 2 yea r s 2 to 3 yea r s 3 to 4 yea r s 4 to 5 yea r s 5 to 6 yea r s 6 to 7 yea r s

T A B L E I

4 7 to 8 yea r s 2 6 8 to 9 yea r s 7

i 6 9 to ro yea r s . 9 5 IO t o I I yea r s . 4

i o 2 i to 22 yea r s . 2 I

A v e r a g e , 5"6 years .

Six hands in four patients had been skin grafted, and the four patients were seen one, two, eight, and ten years post-operatively. In three patients a fifth finger had been amputated. One patient developed an inclusion cyst within a year of operation, one patient had Peyronie's disease, and one had bilateral involvement of the plantar fascia.

Group B, that is those with recurrence, included eight patients and eleven hands. The lesion had been present in seven hands for four to seventeen years, an average of 6- 5 years. All these patients were males, with an average age of 43.6 years. These patients were examined in from nine months to five years post- operatively. In every instance recurrence .had been noted within two years (Table II), and in eight of the hands was in the palm. Two of these hands had been skin grafted: in neither was there recurrence beneath the graft. Four of these patients had a fifth finger amputated. Six had a second operation and were free of disease in one to three and a half years. One of these patients showed

286

D U P U Y T R E N ~ $ C O N T R A C T U R E 287

involvement of the flexor carpi ulnaris, and one had a lesion in the plantar fascia. In one patient an extension of the disease into the thumb-index web was seen one year after operation, but had disappeared completely two years later.

T A B L E I I

Recurrence N o t e d i n m o n t h s 3 h a n d s . N o t e d i n o n e y e a r . z h a n d . N o t e d i n t w o y e a r s . 7 h a n d s .

Group C, those showing recurrence in one hand, with the other hand free of disease post-operatively, included ten patients. The lesion was present prior to operation for an average of 3"8 years (eight patients). All patients were males. The average age was 46"I years. These patients were seen on an average of 4"75 years post-operatively. Recurrence was noted within months in six patients and in one to two years in four patients. Table III shows the time of examination post-operatively in those hands without recurrence.

TABLE III

No Recurrence in One Hand

I to 2 y e a r s 2 6 t o 7 y e a r s z 2 t o 3 y e a r s o 7 to 8 y e a r s o 3 t o 4 y e a r s 2 8 to 9 y e a r s 2 4 t o 5 y e a r s 2 9 to i o y e a r s z 5 t o 6 y e a r s o

A v e r a g e , 4 ' 7 5 y e a r s .

Three of these patients had a skin graft, in each case without recurrence beneath the graft. There were no amputations in this group. Two were operated upon a second time.

Group D comprised eight patients and twelve hands, all of whom developed extension post-operatively. The lesion had been present for an average of 4"4 years pre-operatively (seven hands). All patients were males. Their average age was 45 years. Extension was noted in eleven hands in a few months to two years, in one instance five years. One hand had been grafted, and in one case a fifth finger had been amputated. Bilateral plantar fascial involvement was noted in one patient. An extension was noted in the proximal phalanx of the third finger of one patient which disappeared spontaneously. Two patients had a second operation.

The last group, E, made up of those showing both extension and recurrence, comprised six patients and eleven hands. Four were males. The disease had been present on an average of 34 years (five patients). Table IV indicates the time these patients were seen post-operatively.

One patient had a graft without recurrence beneath it. Three patients had five fingers amputated (fourth and fifth). Recurrence was in the palm in five patients, in the proximal phalanx in six. Extension was noted in relation to the thumb in three, in the thumb-index web in five, and in the proximal phalanx in

288 BRITISH JOURNAL OF P L A S T I C S U R G E R Y

four. One patient had bilateral plantar involvement and one had Peyronie's disease. The average age for the group was 52.3 years.

TABLE I V

Recurrence and Extension Months . 5 i to 2 years 3 3 to 4 years I 4 to 5 years I 6 to 7 years i

Thus there were I2O hands operated upon, of which seventy-seven were free of recurrence or extension when seen on an average of 5-I7 years after operation. Twenty-one hands showed recurrence, eleven extension, and eleven both recurrence and extension. Grafts had been done on thirteen hands and these areas in every instance remained free of disease.

TABLE V

Of ~2o hands of seventy-eight patients operated u p o n - -

2I showed recurrence. I I showed extension. I I showed recurrence and extension. 77 showed neither recurrence nor extension (64 'I6 per cent.).

The incidence of recurrence and extension of Dupuytren's contracture was surprisingly high. Possible factors are incomplete operation, too conservative an operation, and possibly the continuing action of the factor or factors responsible for the lesion. Another factor to be considered but which could not be evaluated in this series is wrong timing of the operation.

To take the last first, early operation, that is before interference with extension, was not done on these patients. Records were not complete enough to justify attempting to assess the degree of involvement at operation. It has always been suggested, and was done in this series, that avoidance of operation during an acute phase of the disease was most desirable.

The amount of recurrence suggests that excision was incomplete. The fact that recurrence did not appear in areas grafted supports the suggestion made by Conway (I954) that the lesion can invade and involve palmar skin. Microscopic examination of fascial lesions excised with adherent skin indicates that such invasion does occur. Thus definite clinical involvement of the palmar skin should mean its excision.

Accurate records of many more patients will be required before a definite answer can be given but it would seem we should be more radical in our handling of skin involvement, and that extension does not occur in a sufficient number of patients or to such a degree as to justify advocating a more extensive primary excision of fascia.

R E F E R E N C E S

CONWA¥, H. (I954). Amer. ft. Surg., 87, Io I . GORDON, S. (I948). Canad. reed. Ass. ft., 58, 543.