Segmental aponeurectomy with Z-Plasty as a treatment option in Dupuytren's disease: A retrospective cohort study.

BACKGROUND: Aponeurectomy remains the reference standard treatment for digit tethering by palmar fascial cords in Dupuytren's disease but is associated with a substantial complication rate. An alternative technique decreases metacarpophalangeal joint (MCPJ) flexion contracture by combining palmar segmental aponeurectomy with Z-plasty skin closure. The primary objective of this study was to assess range of motion of the operated ray after the procedure. The secondary objectives were to assess the complication rate and to determine the recurrence rate after at least 1 year. HYPOTHESIS: Palmar segmental aponeurectomy with Z-plasty closure may provide the advantages of aponeurectomy while decreasing the surgical risk and recurrence rate. MATERIAL AND METHODS: A retrospective study was conducted in 16 patients with predominant MCPJ flexion contracture due to a well-defined palmar fascial cord. Anaesthesia was loco-regional. The Z-plasty design involved a longitudinal incision along the palmar cord with an oblique incision at each end at a 60° angle to the longitudinal incision. The length of the aponeurectomy was about 1.5cm, to allow full MCPJ extension. RESULTS: In all, the 16 patients-13 males and 3 females-had 17 segmental palmar aponeurectomy procedures with Z-plasty closure. Mean operative time was 18minutes. Before surgery, mean loss of extension was 47° at the MCP joint and 15° at the corresponding proximal interphalangeal joint (PIPJ). Immediately after surgery, a 97% improvement in MCPJ extension was noted, leaving a mean extension deficit of 1.25°. Mean follow-up was 18.9 months. No complications occurred. Two patients experienced a recurrence. DISCUSSION: Segmental palmar aponeurectomy as described by Moermans in 1991 improves extension similarly to extensive aponeurectomy but has a lower complication rate. Z-plasty provides good exposure of the pedicles and takes advantage of the greater pliability of the skin on either side of the cord to lengthen the skin by 75%, thereby limiting the risk of the complications seen with needle aponeurotomy. Segmental palmar aponeurectomy with Z-plasty has a role in the management of Dupuytren's disease with flexion contracture predominantly involving the MCPJ.

Anatomical basis of the suprascapular nerve entrapment, and clinical relevance of the supraspinatus fascia.

INTRODUCTION: The entrapment of the suprascapular nerve (SSN) is commonly considered at the level of the suprascapular notch and more rarely in the spinoglenoid notch. Recent per-operative findings showed a compression of the SSN along its course in the supraspinatus fossa. The removal of a fascia for releasing the nerve between the suprascapular notch and spinoglenoid notch led us to purchase an anatomical study. MATERIALS AND METHODS: 30 cadaver shoulders have been dissected. The morphological features about the suprascapular notch, the supraspinatus fascia, and the spinoglenoid notch have been observed. Histological studies of the fascia and the spinoglenoid ligament have been performed. Morphometric parameters such as shape of the suprascapular notch, diameters of the SSN before and after the suprascapular notch, distance between the two notches, length of the course of the SSN into the supraspinatus fossa, diameters of the spinoglenoid notch have been measured. RESULTS: The shape of the suprascapular notch could be seen as "U"- or "V" as previously reported. The fascia was quite constant (completely identified in 29 shoulders) and was the lateral extension of the supraspinatus fascia. The SSN coursed between the bone and the fascia and was surrounded by fat tissue. This fascia was thickened at the level of the spinoglenoid notch and joined the infraspinatus fascia. The spinoglenoid ligament was seen in 28 shoulders. DISCUSSION AND CONCLUSION: In pathologic and post-trauma conditions, the fascia can be retracted or thickened and the SSN may be entrapped along its course in the supraspinatus fossa, between the suprascapular notch and the spinoglenoid notch and without any compression in any notch. These anatomical data lead us to consider that a tunnel syndrome may concern the SSN.