A clinical report of the effect of mechanical stress on functional results after fasciectomy for dupuytren's contracture

doi:10.1016/S0894-1130(02)80004-7

Journal of Hand Therapy

Volume 15, Issue 4, October–December 2002, Pages 331-339

https://doi.org/10.1016/S0894-1130(02)80004-7 Get rights and content

Abstract

Early postoperative treatment after Dupuytren's fasciectomy traditionally has included the application of mechanical stress to digital extension with splints and exercise. This study examines the effect of mechanical stress, which may compromise nutrient delivery to the tissues, on inflammation, flare, hypertrophic scar, digital range of motion (ROM), and therapy visits. The authors compared functional outcomes in operated digits treated postoperatively with tension applied (TA) and no tension applied (NTA), retrospectively from 1983 to 1993 (TA only) and prospectively from 1993 to 1999 (TA and NTA). The charts of 268 patients who underwent Dupuytren's fasciectomy were reviewed and divided into 2 groups (TA and NTA). Each case was analyzed with respect to age, sex, number of digits operated, postoperative management technique, therapy visits, metacarpophalangeal joint, and proximal interphalangeal joint ROM, degree of flare, and scar. There were significant differences in ROM, scar formation, flare, and treatment time in favor of the NTA technique. The results indicate that postoperative management that prevents applied mechanical tension in the early phases of wound healing decreases complications after this surgery and that no digital motion is lost to extension with the NTA technique. J HAND THER. 2002;15:331-339.

Section snippets

Subjects

Data collection for this project was accomplished by a review of 268 patient medical records from 312 available cases of Dupuytren's fasciectomy (Table 1).

. Descriptive Data for Patients in the Study

Empty Cell	*No Tension Applied*	*Tension Applied*
No.	165	103
Male	128	76
Female	37	27
Mean age (SD)	69.33 (6.78)	67.15 (8.91)

There were 44 cases excluded for incomplete data or follow-up. The patients were treated in a single hand therapy practice from 1983 through 1999. The patients were operated on by 49 surgeons, with no

Results

The results of the ANOVA using age, gender, and tension as independent variables indicated that neither gender nor age showed an effect on the time spent in rehabilitation. Also, there was no interaction between the variables of age, gender, and treatment on the number of visits required or the days until discharge. The only significant difference in these measures was seen when comparing TA and NTA. To achieve similar results, the TA cohort required 20 therapy visits compared with 13 for NTA (p

Discussion

Patients in the NTA group had fewer scar complications, developed less flare response, and required less therapy. The final ROM at time of discharge was statistically significant in favor of the NTA protocol, but for practical purposes (differences of 4° to 9° per digit) was not clinically significant. No motion was lost to extension with this protocol. Clinical experience shows that postoperative splinting among hand surgeons and therapists varies from relaxed extension, aggressive extension,

Conclusion

Although this study is limited by methodologic flaws83, 84 relating to the soft methods of evaluating flare and scar, the data support the conclusion that patients treated with no tension and therapeutic exercise with low load and repetition during the early phase of wound healing have better outcomes than patients treated with tension applied. There is no motion lost to extension of the MCP or PIP joints or composite joint flexion with the NTA rehabilitation technique. The large number of

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Is massage an effective intervention in the management of post-operative scarring? A scoping review
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Citation Excerpt :
The effect of mechanical forces on wound healing has recently gained greater attention in the search for improved scar outcomes.3,18 Dupuytren's fascietomy patients treated with a no tension protocol following surgery have demonstrated improved wound healing and scar outcomes compared to those under a tension applied model of care.19 Wounds that are exposed to shear and perpendicular tension in the early stages of healing have been shown to be associated with increases in hypertrophic scarring.20
Scar massage is a widely used treatment modality in hand therapy. This intervention is thoroughly discussed in the literature relating to burns rehabilitation, however, the evidence for its use in treating linear scars following surgery is limited.
To collate the empirical literature on scar massage for the treatment of postsurgical cutaneous scars.
Scoping review.
Medline, EMBASE, CINAHL, AMED, Scopus, ProQuest Dissertations & Theses Global, and the Joanna Briggs Institute were searched from inception to December 2020. Two researchers used a data extraction tool to record key demographic, intervention and outcome data, and to apply the Oxford Levels of Evidence for each study.
Twenty-five studies met the inclusion criteria, reporting on a combined sample of 1515 participants. Only two papers addressed hand or wrist scars (92 participants). While all studies reported favorable outcomes for scar massage, there were 45 different outcome measures used and a propensity towards non-standardized assessment. Intervention protocols varied from a single session to three treatments daily for 6 months. The results from 13 studies were confounded by the implementation of additional rehabilitation interventions.
The overall findings suggest that while there may be benefits to scar massage in reducing pain, increasing movement and improving scar characteristics; there is a lack of consistent research methods, intervention protocols and outcome measures. This scoping review highlights the heterogenous nature of research into scar massage following surgery and supports the need for further research to substantiate its use in the clinical setting.
Does Use of a Night Extension Orthosis Improve Outcomes in Patients With Dupuytren Contracture Treated With Injectable Collagenase?
2021, Journal of Hand Surgery Global Online
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In a retrospective series of 268 patients treated with surgical fasciectomy for Dupuytren contracture, Evans et al23 treated patients after surgery with either a volar orthosis, with tension applied to hold the treated finger in near full extension, or a dorsal blocking orthosis, which blocked tension on the palmar fascia but allowed flexion exercises. They found that patients in the dorsal blocking group (no tension applied) had superior ROM and decreased scar formation.23 It is also possible that the duration of orthosis use in our study was not long enough to demonstrate benefit.
Current prescribing information for the treatment of patients with Dupuytren contracture with injectable collagenase Clostridium histolyticum (CCH) recommends use of a night extension orthosis for 4 months after treatment. The present study examines whether this treatment improves the outcomes.
Adult patients with Dupuytren contracture treated with CCH during the study period were eligible for inclusion. The patients were randomized to orthosis or no orthosis groups and were stratified based on the severity of contracture prior to randomization. The orthosis group was fitted postmanipulation with a hand-based custom orthosis that held the treated finger in maximal comfortable extension, and the patients were instructed to wear the orthosis at night for 3 months. The patients were assessed at 7–10 days, 30 days, and 90 days postmanipulation. Orthosis compliance was measured with a survey. The primary outcome measure was improvement in total active extension (TAE), defined as the sum of active metacarpophalangeal (MCP), proximal interphalangeal, and distal interphalangeal joint extension in the treated finger at 90 days after treatment. Secondary outcomes included total active flexion (TAF), Michigan Hand Questionnaire scores, patient satisfaction, and clinical success.
Twenty-six patients completed the study, 12 in the orthosis group and 14 in the no orthosis group. The majority of contractures (90%) were primarily through the MCP joint. The patients in both the groups demonstrated significant improvements in TAE at 90-day follow-up (orthosis P = .002, no orthosis P = .001) . The difference in improvement in the median TAE between the 2 groups was not significant (P = .40). There were no significant differences between groups for TAE, TAF, Michigan Hand Questionnaire scores, patient satisfaction, or clinical success at any of the time points assessed (P > .05).
In patients with Dupuytren contracture with primarily MCP joint involvement, providing an orthosis after treatment with CCH may not offer a short-term benefit compared with CCH treatment alone in terms of TAE, TAF, or patient-reported outcome measures.
Therapeutic I.
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Both studies showed that a nontension approach, placing the MCP joints in slight flexion, was better than placing extension forces to the MCP joints during wound healing. The nontension approach led to less scar formation and fewer flare reactions.41,42 Orthoses have also been used after treatment with needle aponeurotomy43,44 and after collagenase Clostridium histolyticum (CCH) injection.45
Night Orthosis After Surgical Correction of Dupuytren Contractures: A Systematic Review
2017, Journal of Hand Surgery
Citation Excerpt :
The study by Rives et al,16 although older, scored perfectly on the Newcastle-Ottawa risk of bias scale and did show improvement in patients with orthoses. Evans et al4 also found an improvement with applied tension. In contrast, Glassey17 found an improvement in TAE in the group with the orthosis, along with lower scores on the DASH.
To determine the role of night orthosis use after surgical correction of Dupuytren contracture.
We searched MEDLINE, EMBASE, CINAHL, AMED, OTSeeker, and CENTRAL for articles published from inception of the databases to August 2015. Assessment was undertaken by 2 independent reviewers (O.A.S. and S.A.). Methodological quality of randomized controlled trials was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa instrument.
Seven studies met the standard for inclusion in this review. A total of 659 patients across these 7 studies were included in the analysis, with follow-up ranging from 3 to 72 months. None of the included studies assessed recurrence. The analysis revealed no significant improvement in range of motion of hand joints for patients who received a static night orthosis after Dupuytren surgery compared with patients without an orthosis. Similarly, no differences were found in patient-reported functional status across the 2 groups.
The current literature does not appear to support the use of static night orthosis in addition to hand therapy after surgical correction of Dupuytren contracture.
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^☆: Department of Orthopedics, University of Florida, Gainesville, Florida

^☆☆: Correspondence and reprint requests to Roslyn B. Evans, OTR/L, CHT, Indian River Hand and Upper Extremity Rehabilitation, Inc, Suite E110, 787 37th Street, Vero Beach, FL 32960. E-mail: [email protected].

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Scientific/Clinical ArticlesA clinical report of the effect of mechanical stress on functional results after fasciectomy for dupuytren's contracture☆,☆☆

Abstract

Section snippets

Subjects

Results

Discussion

Conclusion

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Scientific/Clinical Articles
A clinical report of the effect of mechanical stress on functional results after fasciectomy for dupuytren's contracture☆,☆☆