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Background Levator aponeurectomy is a common operation for mild to moderate blepharoptosis. The accuracy of ptosis correction relied on intraoperative judgement when patients were under local anesthesia. For patients who must receive the operation under general anesthesia, it would be an issue to determine how much length of levator aponeurosis to shorten. To solve this issue, we collected data from patients who underwent the operation under local anesthesia and concluded an algorithm. Methods This single-center, prospective bivariate regression study allocated patients of mild to moderate congenital blepharoptosis who received levator aponeurectomy under local anesthesia. Preoperative MRD1 and levator function, intraoperative amount of levator aponeurotic shortening, and postoperative MRD1 were measured. The follow-up period was right after the operation. Results Twenty-nine patients were included in this trial. Two subjects exited because of not receiving allocated operation and data of the other 27 subjects (including 34 eyelids) were analyzed. A scatter diagram was drawn where x axis referred to levator function and y axis referred to the ratio of the amount of shortening of levator aponeurosis over the height of MRD1 correction. Linear regression showed y = − 0.2717*x + 5.026, R 2 = 0.8553. Conclusion A modified algorithm to predict the amount of shortening of levator aponeurosis based on levator function and height of ptosis correction was concluded with better accuracy and clinical feasibility. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background Dupuytren’s contracture is a hereditary disorder which causes progressive fibrosis of the palmar aponeurosis of the hand, resulting in digital flexion contractures of the affected rays. Limited fasciectomy is a standard surgical treatment for Dupuytren’s, and the one with the lowest recurrence rate; however, the recurrence is still relatively high (2–39%). Adipose-derived stem cells have been shown to inhibit Dupuytren’s myofibroblasts proliferation and contractility in vitro, as well as to improve scar quality and skin regeneration in different types of surgeries. Autologous adipose tissue grafting has already been investigated as an adjuvant treatment to percutaneous needle fasciotomy for Dupuytren’s contracture with good results, but it was only recently associated with limited fasciectomy. The purpose of REMEDY trial is to investigate if limited fasciectomy with autologous adipose tissue grafting would decrease recurrence compared to limited fasciectomy alone. Methods The REMEDY trial is a multi-centre open-label randomised controlled trial (RCT) with 1:1 allocation ratio. Participants ( n  = 150) will be randomised into two groups, limited fasciectomy with autologous adipose tissue grafting versus limited fasciectomy alone. The primary outcome is the recurrence of Dupuytren’s contracture on any of the treated rays at 2 years postoperatively. The secondary outcomes are recurrence at 3 and 5 years, scar quality, complications, occurrence of algodystrophy (complex regional pain syndrome), patient-reported hand function, and hypodermal adipose tissue loss at 1 year postoperatively in a small subset of patients. Discussion The REMEDY trial is one of the first studies investigating limited fasciectomy associated with autologous adipose tissue grafting for Dupuytren’s contracture, and, to our knowledge, the first one investigating long-term outcomes of this treatment. It will provide insight into possible benefits of combining adipose tissue grafting with limited fasciectomy, such as lower recurrence rate and improvement of scar quality. Trial registration ClinicalTrials.gov NCT05067764, June 13, 2022.

IntroductionThe partial aponeurectomy for treatment of Dupuytren’s contracture represents the gold standard for treatment of Dupuytren’s contracture. In selected cases, the alternative is the percutaneous needle fasciotomy (PNF).Materials and methodsBetween 2008 and 2018, 80 rays in 64 patients were treated using PNF. 53 patients (68 rays) were reviewed with a mean follow-up of 31 months.ResultsThe recurrence rate was 18.9%. 49 patients with 62 rays had a totally free extension intra-operatively (92.4%). There were no complications. Only one patient reported a transient dysesthesia (1.8%) in the zone of operation. 86% of all patients would undergo the treatment again, if necessary. Patients were able to return to their job in an average of 5.5 days.ConclusionsPNF is reliable and relatively simple to perform compared to partial aponeurectomy. Therefore, the PNF could be seen as a serious alternative for selected cases.

Background: Dupuytren's contractures interfere with physiological gripping. While limited aponeurectomy is an accepted treatment modality to restore finger mobility, methods to objectify functional outcome beyond determination of the range of motion are scarce. Methods: Patients with Dupuytren's contracture being scheduled for unilateral limited aponeurectomy were invited to participate. Clinical data were gathered prospectively by chart review and interview. The DASH-score and flexion contracture for fingers were registered prior to surgery, 3 and 6 months afterwards. At the same time, dynamic manugraphy for simultaneous recording of the grip pattern and forces generated by the affected hand and anatomic areas (i.e., thumb, index finger, middle finger, ring finger, little finger and palm) were performed. All findings obtained during the follow-up period were compared to the situation at baseline. Comparison between paired samples was done using Wilcoxon rank test. All p -values are two-sided and p < 0.05 was considered to be significant. Results: Out of 23 consecutively enrolled patients, 19 (15 men, 4 women) completed follow-up examinations. Manugraphy confirmed the impairment of physiological gripping with concomitant pathological load distribution at base line. Limited aponeurectomy significantly reduced flexion contractures. However, the DASH-score remained at an excellent level in one patient, indicated improvement in 11 and worsening in seven patients. Six patients had lower grip force at t 6 compared to the preoperative condition, although the preoperative flexion contracture (≥110°) was considerably improved in all of them. In four of those, the DASH-score improved while it turned worse in two of them. The force of surgically treated fingers remained unchanged in three patients while it was improved and worsened in half of the remaining patients, respectively. Manugraphy revealed physiological gripping by enlargement of contact area and higher force transmission by the fingertips in 10 of 12 patients with constant or even improved DASH-score and in three of seven patients with a worsened DASH-score. Conclusions: Assessing the reduction of flexion contracture and grip force alone is not sufficient to comprehensively reflect the functional outcome of aponeurectomy for Dupuytren's disease. Visualizing physiological grip pattern provides an additional tool to objectify the success of surgical treatment.

IntroductionDupuytren’s contracture (DC) is a chronic fibroproliferative disorder of the palmar fascia which leads to flexion contracture in one or more fingers. There is no definitive cure for DC, and treatment aims at relieving symptoms by releasing the contracture using percutaneous or operative techniques.Methods and analysisWe planned a prospective, randomised, controlled, outcome assessor-blinded, three-armed parallel 1:1:1, multicentre trial comparing the effectiveness and cost of (1) collagenase clostridium histolyticum injection followed by limited fasciectomy in non-responsive cases, (2) percutaneous needle fasciotomy followed by limited fasciectomy in non-responsive cases and (3) primary limited fasciectomy during short-term and long-term follow-up for Tubiana I–III stages DC. We will recruit participants from seven national centres in Finland. Primary outcome is the rate of success in the treatment arm at 5 years after recruitment. Success is a composite outcome comprising (1) at least 50% contracture release from the date of recruitment and (2) participants in a patient-accepted symptom state (PASS). Secondary outcomes are (1) angle of contracture, (2) quick disabilities of the arm, a shoulder and hand outcome measure (QuickDASH), (3) perceived hand function, (4) EQ-5D-3L, (5) rate of major adverse events, (6) patient’s trust of the treatment, (7) global rating, (8) rate of PASS, (9) rate of minimal clinically important improvement, (10) expenses, (11) progression of disease, (12) progression-free survival, (13) favoured treatment modality, (14) patients achieving full contracture release and >50% improvement and (15) patient satisfaction with the treatment effect. Predictive factors for achieving the PASS will also be analysed.Ethics and disseminationThe protocol was approved by the Tampere University Hospital Institutional Review Board and Finnish Medicine Agency. The study will be performed according to the principles of good clinical practice. The results of the trial will be disseminated as published articles in peer-reviewed journals.Trial registration number NCT03192020; Pre-results.

IntroductionTo evaluate the efficacy of open partial aponeurectomy for recurrent Dupuytren’s contracture.MethodsEighteen patients with recurrent Dupuytren’s contracture of 22 fingers were retrospectively assessed with a mean follow-up time of 94 months (range: 70–114 months). Examination parameters included the determination of range of motion (ROM), grip strength, pain and subjective outcome (disabilities of the arm, shoulder and hand (DASH) questionnaire).Surgical techniqueDissection with special regard to former skin incision and expected wound defect. Modified incisions after Bruner (Mini-Bruner incisions) were facilitated. Dissection started at the palm. Fibrous tissue was resected proximally within the palm including vertical fibrotic septae. Direct preparation of the neurovascular bundles (NVB) was facilitated from proximal to distal. If the anatomy of the neurovascular structures became unclear around the natatory ligament preparation of the NVB at the distal end of the fibrous cord was performed. After complete preparation of a NVB, dissection was continued from medial to lateral until the other bundle was completely released. Transposition flaps and skin transplants were often used for sufficient wound closure.ResultsRecurrence rate was 36 % applying the definition of van Rijssen et al. Fifteen patients had a grip strength of 90 % or higher in comparison to the contralateral side. Ten patients had a pinch strength of 90 % or higher in comparison to the contralateral side. All patients except for one had pain reduction or none postoperatively. Fifteen patients had a DASH score of 15 or lower (range: 0–47). An unrelated ray amputation was suffered due to wound healing complications.ConclusionsOpen partial aponeurectomy performed by a board certified hand surgeon proved to be safe. The postoperative functional outcome seemed to be related to the individual course of the disease.

Zusammenfassung Der M. Dupuytren ist eine fibroproliferative Systemerkrankung, die medikamentös nicht geheilt werden kann. Die Gesamtprävalenz beträgt 7–8 %. Männer sind 3‑ bis 4‑mal häufiger betroffen. Die Ursache der Erkrankung ist nicht geklärt. Eine genetische Disposition und familiäre Häufung werden diskutiert. Risikofaktoren für die Entstehung eines Dupuytren-Strangs sind berufsbezogene Belastungen (Mikrotraumata), Nikotin- und Alkoholkonsum, Epilepsie, Diabetes mellitus und zunehmendes Lebensalter. Eine schlechte Prognose besteht u. a. bei positiver Familienanamnese, bilateralem Befall, Alter < 50 Jahren und männlichem Geschlecht. Die Erkrankung ist eine Blickdiagnose. Therapeutisch stehen mehrere Verfahren zur Auswahl; die konservative Therapie zeigt keinen dauerhaften Nutzen. Minimalinvasive Verfahren sind die partielle Nadelaponeurotomie oder die Injektion einer Kollagenaselösung. Operative Verfahren reichen von der partiellen Aponeurektomie bis zur Dermatoaponeurektomie. Das Rezidivrisiko der operativen Goldstandardtherapie (partielle Aponeurektomie) beträgt 20,9 %.

IntroductionMany surgical techniques have been advocated to treat Dupuytren’s contracture. Partial fasciectomy is often performed to treat the whole spectrum of Dupuytren’s disease.MethodWe have reviewed the effectiveness of total aponeurectomy performed on 61 patients [10 women and 51 men (male:female ratio 5.1:1) with a mean age of 63.0 (range 42–79 years) and a mean follow-up of 3.45 years (range 1.03–6.39 years)].ResultsPost-operative complications including haematoma, seroma or necrosis were found in 13.8% of the patients. Recurrence of contracture occurred in 10.8% of the patients and 4.6% of the operated patients presented with a nerve lesion. Nerve irritation occurred in 6.2% of the patients. The mean DASH-score was 3.85 (range 0–52.5). Family pre-disposition was an important risk factor for Dupuytren’s disease with 44.3% of patients having a positive family history.ConclusionWe suggest that total aponeurectomy is a promising alternative to partial fasciectomy with low risk for a recurrence and slightly increased risk for a nerve lesion.

Dupuytren’s contracture is a fibroproliferative disorder causing cosmetic and functional deficits of the hands. Surgical intervention is typically recommended when the contractures of the metacarpophalangeal and proximal interphalangeal joints reach 30° and 15–20°, respectively. Collagenase injections and percutaneous fasciotomy have a role in the treatment of select patients and are discussed elsewhere in this textbook. At present, partial fasciectomy remains the gold standard treatment option, particularly for severe, extensive, or recurrent contractures. Open fasciotomy, segmental aponeurectomy, and radical fasciectomy are less commonly utilized. Dermatofasciectomy is useful in cases of severe contractures or recurrence, especially when the disease has become intimately involved in the overlying skin. Alternatively, the open palm technique is a well-established and successful treatment option in cases of contracture correction with resulting skin deficit. The open wound heals by secondary intention. Surgical fasciectomy is typically a well-tolerated outpatient procedure with low risk of serious complication. Operative management focuses on resection of diseased tissue only and careful protection of neurovascular structures. Patients must be counseled on the risk of recurrence and/or extension, which varies from 8 to 54 %. Early-onset disease and ectopic foci increase this risk further. Postoperative management focuses on wound healing and early motion exercises.

Life table analysis was used to evaluate the recurrence rate after segmental aponeurectomy for Dupuytren's disease. From this analysis, factors that play a role in the progress of the disease after surgery have been defined. A mathematical model has also been created which could serve as a baseline to compare the results after segmental aponeurectomy with those of other techniques. The introduction of corrective factors allowing for the different follow-up periods gives, by projection, a proportion of 68% of recurrence after ten years. This high percentage of recurrences to which a number of extensions should be added confirms that surgery is not curative in Dupuytren's disease; after ten years, almost no hand would be left clear of the disease. Patients operated on before the age of 45 or having ectopic sites of the disease run a higher risk of recurrence. No other factors, local or general, play a statistically significant prognostic role.