Outcome of arthrodesis for severe recurrent proximal interphalangeal joint contractures in Dupuytren’s disease

Introduction

The surgical options for severe recurrent proximal interphalangeal (PIP) joint contracture in Dupuytren’s disease include joint release, amputation, middle phalanx excision, distraction and arthrodesis. To obtain the optimal position of function in arthrodesis for severe Dupuytren’s PIP joint contracture, removal of a large dorsal wedge of bone is usually needed to obtain sufficient PIP joint extension.

We have combined arthrodesis with a segmental fasciectomy or needle fasciotomy to achieve extension, in an effort to preserve digit length by removing a minimal amount of bone. The aim of this study is to report the longer-term outcomes after PIP joint fusion in patients who would otherwise have been treated with a third revision fasciectomy or dermofasciectomy with a PIP joint release, or amputation of the digit.

Methods

The study cohort was identified retrospectively through the theatre coding records searching for the terms ‘arthrodesis’ and ‘fusion’ in procedures carried out by three surgeons (HG, IM and MS) during the period 2003–2020 in a single specialist hand centre. Patient records were scrutinized to confirm that a PIP joint arthrodesis had been done to treat recurrent Dupuytren’s disease. Age at time of surgery, digit involvement, previous operations for Dupuytren’s disease, the preoperative degree of contracture, any further clinical review for the same condition and any further hand surgery after arthrodesis were noted. Patients were contacted by telephone with a questionnaire enquiring about satisfaction and whether they would undergo this procedure again or recommend it to family and friends, their return to activities, any change in finger posture or function since surgery and any need for further review or intervention since discharge.

Results

Eleven patients were identified with a mean age of 64 years (range 53–73) at the time of surgery. Ten patients had PIP joint arthrodesis in the little finger, five in the left hand. One had PIP joint arthrodesis in the right ring finger. The mean contracture of the PIP joint before surgery was 102° (range 80°–120°). A concomitant needle or segmental fasciectomy was done at the time of arthrodesis in ten of the 11 patients.

All patients had undergone two previous procedures to correct Dupuytren’s contracture of the same joint. Eight had previously undergone a fasciectomy and revision fasciectomy or dermofasciectomy with a mean time interval of 66 months (range 12–107) between the last revision fasciectomy and the arthrodesis procedure. The other two patients had previously undergone a needle and subsequently a segmental fasciectomy. The mean follow-up was 8 years 9 months (range 9–199 months). During this period all patients have been reviewed for Dupuytren’s finger contractures in the contralateral hand, or for unrelated hand conditions, such as osteoarthritis. There were no wound healing problems. Postoperatively the patients attended for hand therapy for periods of between 3 and 7 weeks. In accordance with surgeon preference, some had PIP joint splinting for 6 weeks, whereas others were not splinted. Arthrodesis was confirmed clinically and radiographically in all cases. No patients reported a change in finger posture or further surgery to the operated finger after the arthrodesis. They reported that they were able to carry out normal activities of daily living, and those of working age returned to their previous occupation. All patients expressed a willingness to undergo this procedure in another finger if required and all would recommend this operation to relatives and friends. A third of patients commented that recovery and return to daily activities were quicker after this operation than after previous surgery. None of the patients reported numbness or cold intolerance. Removal of the wires was not required in any of the cases.

Discussion

There is a high recurrence rate after primary surgery for contractures of the PIP joint >60°, which is even higher after secondary surgery for recurrent Dupuytren’s disease (Misra et al., 2007). The patients in this series with a third recurrence of severe PIP joint contractures despite two previous fasciectomies were at high risk of further recurrence or poor outcome with a third fasciectomy or dermofasciectomy. They were instead offered PIP joint arthrodesis or amputation. The patients universally chose PIP joint arthrodesis and this was done, after achieving appropriate functional digital extension by segmental fasciectomy or fasciotomy rather than bone excision.

Watson and Lovallo (1987) used arthrodesis on a similar cohort of 11 patients with severe recurrent Dupuytren’s joint contractures using a concave–convex arthrodesis technique. All the patients in their series achieved union at 6 weeks and at final assessment had a satisfactory result with a mean follow-up of 4 years (range 6–113 months). The only complication was a subsequent fracture through the arthrodesis in one patient. No surgery was required for recurrence of Dupuytren’s disease. They did not release the contracture before arthrodesis; instead they shortened the proximal phalanx significantly to correct the deformity and achieve an angle of 30° in the little finger and 37° in the ring finger. The only major functional complaint in two patients was the inability to hold small objects in the ulnar aspect of the palm. This has not been a complaint in our experience, but each patient has specific functional needs that must be taken into account when deciding upon the angle of arthrodesis.

Excision of the middle phalanx is an alternative technique to correct the PIP joint contracture and aid fusion. It has been reported in 40 patients with successful union but 33% had cold intolerance and 11% sensory loss (Honecker et al., 2016; Raimbeau et al., 2019). This technique results in significant shortening of the finger, which could cause functional problems.

Nonunion after arthrodesis of the PIP joint for all indications using a Kirschner-wire and tension band construct occurs in 1%–5% (Satteson et al., 2015). We had no cases of nonunion. This could be attributed to the small number of patients, but nonunion of the PIP joint does not appear to be a significant problem in patients with Dupuytren’s disease independent of the technique used (Honecker et al., 2016; Watson and Lovallo, 1987).

A limitation of this study is the use of subjective patient outcomes reported by telephone consultation rather than clinical assessment. Functional assessment is subjective and dependent on lifestyle and age. This limitation is mitigated by previous reports that show a disparity between objective and subjective outcomes in Dupuytren’s disease (Norotte et al., 1988; Roush and Stern, 2000). Patient-reported outcome measures were not used as these are not sensitive or specific enough to isolate the outcome of a single digit in a multi-digit disease. Another limitation is the small number of patients, but they are at the severe end of the spectrum of Dupuytren’s disease and other series are of a similar size (Watson and Lovallo, 1987).

We consider PIP joint arthrodesis to be a salvage operation reserved for the treatment of severe recurrence of PIP joint contractures after two previous operative interventions to the same joint in the same finger. After obtaining a functional position of the PIP joint by needle fasciotomy or segmental fasciectomy, the use of tension band fixation reliably achieves fusion and has negligible complications. The long-term outcomes show high patient satisfaction, fairly rapid return to function with no requirement for revision surgery.