Randy H,
What are you trying to say? I have no idea what you are talking about. Do you know what a limited fasciectomy is?

"WHAT!!! You had a *What*.......a *Limited* fasciectomy? You mean you've *never* had your hand fully opened, torn to shreds removing all the Dups tissue with scars 4 to 5 inches long? You've *never* had Traditional, Fully Open and Invasive Dups Surgery? Yipes! This disclosure must have been repeated in the record of our debates numerous times, and yet I never noticed it! How *blind* *I* have been! All this time when you said "surgery"

Evolution of surgical management
The primitive anaesthesia techniques of the early 19th century implied limited and swift surgery. Dupuytren himself suggested simple fasciotomies through small transverse incisions staged in the palm and on the first phalanx.

As advances in anaesthesia and wound management made more sophisticated surgery possible, the limited surgery of the beginnings became more complex. Many different patterns of skin incisions associated with more or less extensive fasciectomies have been described the choice of the skin approach being influenced by the extent of the planned fascial dissection.



2.4.1 Fasciotomy
Simple release of the contracted fascia can result in prolonged or permanent release of the contracture as has been demonstrated by the correction of the contracture after trauma (Grace et al., 1984). Historically open and closed wound approaches have been used for fasciotomy (McGrouther 1990d). Open wound release was performed among others by Dupuytren. Closed fasciotomy was advocated by Sir Astley Cooper (1822) by the subcutaneous division of a band with a pointed bistoury introduced through a small wound in the skin; a splint was then applied to maintain the finger in a straight position.

As the frequency of recurrence became apparent, simple fasciotomy was progressively given up except by some surgeons if the band is well defined and bow-stringing (Colville 1983, 1990) or for the division of bands proximal to the distal palmar crease (Rowley et al. 1984).
Gonzales (1971, 1985, 1990) has advocated either a fasciotomy or a limited fasciectomy in the digits with interposition of Wolfe grafts. The operation of fasciotomy and graft (McGregor 1985) requires division without dissection of the retracted cords.



2.4.2 Radical palmar fasciectomy
Goyrand has been credited with the first fasciectomy. As for simple fasciotomies, the concept of limited fasciectomy was to become unpopular because of the likelihood of recurrences.
Radical palmar fasciectomies were proposed at the turn of the 20th century when more extensive operations became technically possible and when it was realized that recurrences were frequent after less extensive operations. The technical details of this type of operation were clearly explained by McIndoe & Beare (1958). They proposed a single transverse palmar incision with a very wide undermining in direction of the wrist and of the finger. The proposed excision was really very radical since even the natatory ligaments were removed in the block dissection. The fingers were approached through Z incision centred on the digital midline. The entire palmar fascia was removed in a single block extending into the finger by undermining. Great emphasis was placed on dressings to prevent haematoma formation.


2.4.3 Limited fasciectomy
Hueston (1961) emphasized that the then poor reputation of operations for Dupuytren's disease had largely arisen from complications and that the radical palmar clearance which was then in vogue was particularly responsible. He defined his operation, 'limited fasciectomy', as 'the excision of the palpably thickened fascia with a narrow margin of normal aponeurosis'. Hueston approach can be considered as a near total fasciectomy in the involved rays extending from the mid-palm to the base of the second phalanx (McGrouther 1990d). Hueston's article in the Plastic and Reconstructive Surgery journal was to establish the ground rules for the next quarter century. The advantages perceived by Hueston were a simpler operation than radical fasciectomy with a simpler return of normal function. He found no difference in the rates of recurrence or extension compared with the more radical approaches.

Many other authors moved from radical to limited fasciectomies following the principles stated by Hueston. Further technical refinements were described by Skoog (1967, 1985) who introduced an anatomically precise operation preserving the transverse fibres of the aponeurosis which are not involved by the disease.


Another approach was proposed by McCash (1964) who felt that the impaired vitality of the palmar skin after limited fasciectomies made through zigzag incisions or straight incisions converted to Z plasties was the source of many problems. Those skin flaps were thus undesirable. Skin grafts impose the immobilization of the hand and he also felt that they should be avoided. His approach was to make incisions in the transverse skin creases and to move the undermined skin bridges so that the skin shortage is transferred to the distal palmar crease incision which remains wide open. Only the diseased fascia has to be removed. The open wound is dressed at weekly interval. The wounds generally close in 2-5 weeks and since they remain open, there is no possibility for an haematoma to collect. A disadvantage of the open palm technique is that the patients are apprehensive about the open wound. The great merit of the method is its safety. Nevertheless, it only partially solve the problem of the finger contracture.




Figure 2-7: Hueston's (left) and Skoog's approaches



2.4.4 Dermofasciectomy
The elective excision of skin involved in recurrent Dupuytren's disease was proposed by Hueston (1962). His belief was that the palmar dermis exerts some form of control on the disease process and that the simultaneous excision of the diseased aponeurosis and of the overlying skin at the proximal segment of the digit from one neutral line to the other, could prevent recurrences.
Smaller skin grafts have also been proposed by Gonzales (1971, 1985, 1990) and McGregor (1985) to break up the contracture line.


2.5 Conclusion
Dupuytren's contribution to the description of the contracture that now bears his name was fundamental even though other surgeons had analysed some of its manifestations before him and many aspects of the disease were more intricate than he suspected. His presentation and the passionate discussions that ensued raised many questions that are not yet answered today:

which is the role of chronic local trauma;

which is the part played by heredity;

why is the disease more frequent in the ulnar rays;

what is the origin of the digital cords if one assumes that the palmar fascia does not extend into the digits?

Without clear answers to these questions, the surgical approach of Dupuytren's disease has swayed from the very simple closed fasciotomy to the very aggressive radical palmar fasciectomy. The less traumatising techniques were often found insufficient to correct the contracture and to bring a lasting improvement. The more aggressive operations were developed on the unfounded hope that recurrences could be avoided. This has never been proved and these techniques were responsible for a great number of complications.

Two intermediate approaches are currently in favour: the limited fasciectomy proposed among others by Hueston and further refined by Skoog (fig. 7) and the open palm technique of McCash.

There is nothing in your first paragraph from Dr. Eaton that I disagree.