Percutaneous Aponeurotomy and Lipofilling (PALF)

Dupuytren disease is a progressive fibroproliferative disorder, which leads to flexion contractures of the digits. A minimally invasive technique consisting of an extensive percutaneous aponeurotomy of the cord with a needle combined with lipofilling is presented. The selective cutting of the cords under continuous tension disintegrates the cords while sparing the looser neurovascular bundles. Subsequently, lipoaspirate is injected subcutaneously. The authors’ prospective results show a significantly shorter recovery time and less overall complications in this technique when compared with open surgery, while no significant difference was observed in the extent of immediate contracture correction and in the recurrence rate at 1 year follow-up.

Key points

  • Extensive percutaneous aponeurotomy and lipofilling (PALF) is a minimally invasive surgical technique. No incisions are made, no tissue is removed, and no sutures are used.

  • Patients are able to return to normal activities after a median of 9 days. The technique is safe. Due instead of owing to the strong extension force applied on the contracture, the needle tip selectively severs the cords placed under tension while the looser neurovascular bundles are spared. Lipofilling restores the subdermal fat deficiency, which is an inherent part of the pathology of Dupuytren contracture.

  • Adipose-derived-stem cells (ADSCs) in the lipoaspirate may inhibit proliferation of the contractile myofibroblast.

  • When comparing PALF with limited fasciectomy (LF), no significant differences are observed in overall postoperative contracture correction and in recurrence of the contractures within 1 year follow-up.

Introduction

Dupuytren disease (DD) is a chronic progressive fibroproliferative disease characterized by flexion contractures of the digits, especially the metacarpophalangeal (MP)-joint and proximal interphalangeal (PIP) joints. In DD, the formation of palmar nodules have classically been described as the first sign of the disease, which are the result of myofibroblast proliferation and extracellular matrix synthesis. Myofibroblasts are the cells responsible for the development of the disease. In the later stages of DD, nodules mature to form collagen-rich, acellular fibrotic cords, which lead to digital contractures.

The disease is more prevalent in the Northern part of Europe. Males are more affected than females, and it is more common in older patients. Family predisposition and genetic pathways are described for DD. Other factors such as smoking, alcohol consumption, manual work, hand trauma, diabetes, and epilepsy have also been linked to DD. Factors that contribute to the severity of the disease, also known as diathesis, are (1) bilateral hand involvement, (2) ectopic disease, (3) family members with DD, and (4) early onset of the disease. In patients with severe diathesis, the disease is more likely to recur after treatment.

Many treatment options are available to treat the symptoms of DD. Established flexion contractures are most commonly treated by surgical excision of the cord through a limited fasciectomy (LF). Complications after surgical treatment include pain, edema, paresthesia, infections, hematoma, nerve lesions, arterial lesions, tendon ruptures, and chronic regional pain syndromes (CRPSs). The overall cumulative complication rate for LF reported in a randomized controlled trial was 30%. Recently, a 20.9% recurrence rate 5 years postsurgery has been described for LF.

The prolonged postoperative recovery of the LF has led to a trend toward minimally invasive techniques in the past 10 years. These techniques include needle aponeurotomy (NA) and collagenase injections, which enzymatically digest and weaken the cord. These minimally invasive methods are gaining more popularity as treatment of DD, despite the higher recurrence rates associated with them.

In an attempt to overcome the high recurrence rates after NA, the authors’ group is investigating a new treatment strategy, a more extensive percutaneous aponeurotomy that is performed while maintaining the cord under tension followed by lipofilling of the loosened structure. The grafted lipoaspirate is known to contain stem cells, and there is now increasing evidence that stem cells may be used to treat fibrotic diseases. The authors’ study showed that ADSCs inhibit proliferation of the contractile myofibroblasts and mediate these effects by soluble factors, influenced by cell contact. Myofibroblasts are the key cells leading to the development of fibrosis and flexion contractures in DD. Therefore, inhibiting myofibroblasts using a lipoaspirate containing ADSCs represents a rational treatment strategy for DD.

Furthermore, DD is associated with subdermal fat deficiency and atrophy as the pathologic fibrosis displaces the fat. Fat grafting is able to restore the loss of this important padding. Fat has already been used in the early twentieth century to infiltrate the diseased area in an attempt to treat flexion contractures of the digits. As fat grafting has gained popularity over the past decade, the authors reintroduced this procedure for DD. Their findings lend support to the potential benefit of lipofilling in conjunction with an extensive needle fasciotomy of the cord as a new strategy in the treatment of DD.

Introduction

Dupuytren disease (DD) is a chronic progressive fibroproliferative disease characterized by flexion contractures of the digits, especially the metacarpophalangeal (MP)-joint and proximal interphalangeal (PIP) joints. In DD, the formation of palmar nodules have classically been described as the first sign of the disease, which are the result of myofibroblast proliferation and extracellular matrix synthesis. Myofibroblasts are the cells responsible for the development of the disease. In the later stages of DD, nodules mature to form collagen-rich, acellular fibrotic cords, which lead to digital contractures.

The disease is more prevalent in the Northern part of Europe. Males are more affected than females, and it is more common in older patients. Family predisposition and genetic pathways are described for DD. Other factors such as smoking, alcohol consumption, manual work, hand trauma, diabetes, and epilepsy have also been linked to DD. Factors that contribute to the severity of the disease, also known as diathesis, are (1) bilateral hand involvement, (2) ectopic disease, (3) family members with DD, and (4) early onset of the disease. In patients with severe diathesis, the disease is more likely to recur after treatment.

Many treatment options are available to treat the symptoms of DD. Established flexion contractures are most commonly treated by surgical excision of the cord through a limited fasciectomy (LF). Complications after surgical treatment include pain, edema, paresthesia, infections, hematoma, nerve lesions, arterial lesions, tendon ruptures, and chronic regional pain syndromes (CRPSs). The overall cumulative complication rate for LF reported in a randomized controlled trial was 30%. Recently, a 20.9% recurrence rate 5 years postsurgery has been described for LF.

The prolonged postoperative recovery of the LF has led to a trend toward minimally invasive techniques in the past 10 years. These techniques include needle aponeurotomy (NA) and collagenase injections, which enzymatically digest and weaken the cord. These minimally invasive methods are gaining more popularity as treatment of DD, despite the higher recurrence rates associated with them.

In an attempt to overcome the high recurrence rates after NA, the authors’ group is investigating a new treatment strategy, a more extensive percutaneous aponeurotomy that is performed while maintaining the cord under tension followed by lipofilling of the loosened structure. The grafted lipoaspirate is known to contain stem cells, and there is now increasing evidence that stem cells may be used to treat fibrotic diseases. The authors’ study showed that ADSCs inhibit proliferation of the contractile myofibroblasts and mediate these effects by soluble factors, influenced by cell contact. Myofibroblasts are the key cells leading to the development of fibrosis and flexion contractures in DD. Therefore, inhibiting myofibroblasts using a lipoaspirate containing ADSCs represents a rational treatment strategy for DD.

Furthermore, DD is associated with subdermal fat deficiency and atrophy as the pathologic fibrosis displaces the fat. Fat grafting is able to restore the loss of this important padding. Fat has already been used in the early twentieth century to infiltrate the diseased area in an attempt to treat flexion contractures of the digits. As fat grafting has gained popularity over the past decade, the authors reintroduced this procedure for DD. Their findings lend support to the potential benefit of lipofilling in conjunction with an extensive needle fasciotomy of the cord as a new strategy in the treatment of DD.

Treatment goals and planned outcomes

DD is a chronic progressive disease, and all currently available treatments only address the symptoms rather than treating the underlying pathologic condition. Therefore the goals are to maximally straighten the finger, to shorten the convalescence period and to delay recurrence with a minimum of complications. Outcome measures are therefore patient satisfaction, convalescence period, and objective measurements of range of motion and of contracture recurrence.

Preoperative planning and preparation

The procedure is ideally suited for patients who want to minimize recovery time. A great advantage of this new technique is its ability to treat multidigital ray disease in one session, where conventional open surgery would require extensive dissection of every ray through multiple stages.

Younger patients, especially women, with severe diathesis or with recurrent PIP joint contractures are less-ideal candidates. Long-standing PIP joint contractures are difficult to release fully with this technique because of inherent joint contracture and attenuation of the extensor tendon central slip. The authors advise not to treat patients who had previous surgery with flaps in the affected area because the scarred neurovascular bundles are no longer loose and therefore are as vulnerable to be severed by the needle as the recurrent cord and the surrounding scar tissue.

To treat the cords and nodules and to free the affected skin from the underlying pathologic process, a 19-gauge needle and a malleable semi-rigid hand retractor is needed. After infiltration of the designated liposuction donor area (typically the abdomen) with a mixture of 500 mL of 0.9% NaCl, 20 mL lidocaine, and 0.5 mg epinephrine and bicarbonate, a syringe liposuction using a blunt tip cannula with multiple holes is performed. Patients can be treated either in an outpatient clinic with proper facilities or in day care. Anesthesia can be provided in the following ways: (1) locoregional block for the upper extremity combined with local anesthesia for the liposuction area, (2) general anesthesia, (3) peripheral isolated or combined nerve block together with local anesthesia for the liposuction area, and (4) local superficial anesthesia of the affected fingers combined with local anesthesia for the liposuction area.

The duration of the minimal invasive procedure depends on the number of digital rays involved and the extent of the disease and typically requires the same operative time as LF.

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Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Percutaneous Aponeurotomy and Lipofilling (PALF)
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