掌腱膜挛缩症的临床及病理基础

目的 :探讨掌腱膜挛缩症的病理改变与疗效之间的关系 ,为合理选择手术方式提供依据。方法 :对 2 6例掌腱膜挛缩症患者共 2 9只手进行手术治疗 ,其中 12只手单纯作掌腱膜切除术 ,17只手行掌腱膜切除 受累皮肤切除术 ,对其疗效进行平均 4.6年的随访 ;并对 2 4例掌腱膜标本作病理学及免疫组化检测。结果 :所有行免疫组化检测的病变掌腱膜标本中均有α -平滑肌肌动蛋白的表达 ;单纯掌腱膜切除组的术后复发率为 5 8.33 % ,掌腱膜切除 受累皮肤切除组术后复发率 11.76 %。结论 :掌腱膜挛缩症的病理改变不仅仅局限在掌腱膜 ,也可累及皮下组织和皮肤。因此 ,对病变已侵及皮肤的病例应作掌腱膜切除 受累皮肤切除术。     

滨腱挛缩症的临床及病理基础

目的：探讨掌腱膜挛缩症的病理改变与疗效之间的的关系，为合理选择手术方式提供依据。方法：对２６例掌腱膜空症患者共２９只手进行手术治疗，其中１２只手单纯作滨腱膜切除术，１７只手行掌腱切除＋受累皮肤切除术，对其疗效进行平均４．６年的随访；并对２４例滨腱膜标本作病理学及免疫组化检测。结果：所有行免疫组化检测的病变掌腱膜标本中均有α－平滑肌肌动蛋白的表达；单纯掌腱膜切除组的术后复发率为５８．３３％，掌腱膜切     

“Z”字成形术与游离植皮术治疗掌腱膜挛缩症的比较

目的:讨论掌腱膜挛缩症的病因、发病机制及治疗方法。方法:总结和分析经手术治疗的掌腱膜挛缩症31例(46只手)。行掌腱膜大部切除、手掌及手指挛缩皮肤“Z”字成形术9例(14只手),男8例,女1例;年龄24-78岁,平均(57.2±14.6)岁。行掌腱膜及受累皮肤一并切除加游离植皮术22例(32只手),男20例,女2例;年龄23-64岁,平均(53.7±8.9)岁。结果:随访3个月-14年,平均5年8个月。单纯掌腱膜切除组术后复发率为42.9%(6/14),掌腱膜切除加受累皮肤切除组术后复发率12.5%(4/32),两组术后复发率比较2χ=5.275,P<0.05(P=0.022),差异有显著性统计学意义。结论:彻底切除病变组织,有利于降低手术后的复发率。     

掌腱膜部分切除术治疗掌腱膜挛缩症

目的 探讨掌腹腱膜挛缩症治疗的临床经验。方法 1980年以来，我院共治疗掌腱膜挛缩症22例，全部采用掌腱膜部分切除术。结果 19例病人获得满意的治疗效果，应用Tubiana’s法评价，手术后优良率为86．4％，效果良好。结论 本手术成功的关键在于：仔细分离皮瓣，避免皮肤坏死；避免血管神经束损伤；彻底切除挛缩腹膜，避免术后复发；彻底止血，防止血肿形成和感染；术后早期进行功能锻炼。     

小指近侧指间关节掌腱膜挛缩症的治疗

目的探讨小指近侧指间关节掌腱膜挛缩症的治疗方法。方法2000年以来，我院共治疗9例（15侧）小指近侧指间关节掌腱膜挛缩症的患者，采用指掌侧挛缩皮肤“Z”字成形，并在扩大切除掌腱膜的同时，切除受累小指的中央索、螺旋索、侧方指膜、小鱼际肌向小指近侧指间关节移行的尺侧腱膜及小指近侧指间关节处骨化的腱膜。结果术后14侧切口Ⅰ期愈合；1侧皮肤部分坏死，换药后愈合。术后随访时间8个月～2年，平均1．6年，小指能完全伸直，皮肤无挛缩，手指屈伸活动基本正常，术后无其他并发症，无1例复发。结论小指掌腱膜切除的同时，应将受累指的中央索、螺旋索、侧方指膜、小鱼际肌向小指近侧指间关节移行的尺侧腱膜及小指近侧指间关节处骨化的腱膜一并切除。     

Dupuytren挛缩手术中手掌手指皮瓣的设计

目的探讨Dupuytren挛缩手术中手掌手指局部转移皮瓣的设计方法。方法自1997年以来，我院共治疗Dupuytren挛缩症39例48手，根据挛缩程度、部位设计改良“Z”形皮瓣，采用掌腱膜部分切除术治疗Dupuytren挛缩症。结果应用Tubiana’s法评价，手术优良率为87．5％，效果良好。结论在行Dupuytren挛缩症手术前，需要仔细设计手掌手指皮瓣，避免血管神经束及肌腱损伤；彻底切除挛缩腱膜、术后早期进行功能锻炼也是手术成功的关键。     

掌腱膜桡侧挛缩的临床特点与治疗

目的探讨掌腱膜桡侧挛缩的病变特点和临床疗效。方法对8例因掌腱膜桡侧挛缩行手术治疗的病例进行回顾性研究。8例的病变均位于虎口和大鱼际区域，表现为皮肤纠集、结节和条索，很少影响拇指的活动范围。均手术切除局部的掌腱膜条索。7例患者获得随访，平均随访25．1个月；1例失访。结果掌腱膜桡侧挛缩多与尺侧挛缩并发，手术治疗总体疗效较好，仅有1例复发。术后病理证实切除的组织为挛缩的掌腱膜。结论掌腱膜桡侧挛缩的发病部位集中于第一掌指关节的掌侧、大鱼际尺侧、虎口部位和大鱼际桡侧，未见累及指问关节，手术治疗可取得良好效果。     

邻指皮瓣联合“Z”字成形术治疗严重屈曲畸形的掌腱膜挛缩症

目的探讨应用邻指皮瓣联合"Z"字成形术修复严重屈曲畸形的Ⅲ期以上掌腱膜挛缩症的手术方法和临床疗效。方法 2014年9月-2017年12月,对8例Ⅲ期以上严重屈曲畸形的掌腱膜挛缩症患者,通过设计连续的"Z"字皮瓣联合邻指皮瓣,切除挛缩掌腱膜,保留神经血管束,皮瓣交叉转移后修复缺损创面,邻指皮瓣供区行游离皮肤移植。结果术后8例皮瓣全部成活,随访10～48个月,无一例复发,皮瓣质地及外形满意。按中华医学会手外科学会上肢部分功能评定试用标准评定:患手运动功能优7例,良1例,优良率为100%。结论应用邻指皮瓣联合"Z"字成形术修复严重屈曲畸形的掌腱膜挛缩症,术后临床效果满意,是治疗严重屈曲畸形掌腱膜挛缩症的一种有效方法。     

掌腱膜挛缩症的手术治疗

目的 探讨掌腱膜挛缩症手术方法的改进,分析其疗效.方法 2008年9月至2009年8月,采用掌腱膜部分切除术治疗掌腱膜挛缩症患者9例11侧,对传统的治疗方法加以改进,以游离植皮的理念处理掌侧皮瓣.结果 本组患者术后切口均Ⅰ期愈合,无皮下血肿、皮缘坏死、切口感染等术后早期并发症发生.随访1～6个月,平均3.3个月,无一例复发.按中华医学会手外科学会上肢部分功能评定试用标准评定:患手运动功能优9例,良2例;优良率为100%.结论 在掌腱膜部分切除术中以游离植皮的理念处理掌侧皮肤可明显降低术后早期并发症.     

手术显微镜下切除掌腱膜治疗掌腱膜挛缩症的方法及体会

１８２３年法国Ｄｕｐｕｙｔｒｅｎ报告掌腱膜挛缩症是由于掌腱膜挛缩而引起的手部继发性畸形。我院自１９８０年以来，在手术显微镜下切除掌腱膜治疗掌腱膜挛缩症２１例，收到良好的效果。１临床资料本组男１８例，女３例，年龄１９～７４岁，平均５３岁。工人１７例，干...     

Dupuytren's contracture: morphological and biochemical changes in palmar aponeurosis

The palmar aponeurosis removed from ten patients with Dupuytren's contracture was studied using morphological and biochemical approaches. The histological characteristic of Dupuytren's contracture is the presence of numerous nodules among the lamellar structures of the collagen fibres. In the nodules, there are many active fibroblasts which are surrounded by immature fibres and metachromatic substances demonstrated by toluidine blue staining. Ultrastructurally, the active fibroblasts have the characteristics of myofibroblasts, as previously reported by Dr. Gabbiani. We found that some fibroblasts have intracellular collagen fibrils in the cytoplasm. When assayed by Siegel and Martin's method, lysyl oxidase activity of the palmar aponeurosis was significantly higher in Dupuytren's contracture than in normal hands. Biochemical studies such as electrophoretic analysis of mucopolysaccharides, determination of uronic acid and collagen contents were undertaken to compare the aponeurosis of Dupuytren's contracture with normal cases. The uronic acid contents were higher in Dupuytren's contracture than in the controls. However, no difference between the two groups was found in the collagen contents and in the composition of the mucopolysaccharides. These characteristic features; existence of myofibroblasts and intracellular collagen fibrils and increase in the activity of lysyl oxidase probably play a significant role in the establishment of flexion contracture of the fingers in Dupuytren's contracture.     

Dupuytren's cord involving the septa of Legueu and Juvara: a case report

A patient with Dupuytren's disease with involvement of the palmar fascial complex and digital contracture is described. A vertical cord had developed in the transverse ligament of the palmar aponeurosis fibers and the underlying septa of Legueu and Juvara. The cord was composed of a pretendinous band, transverse ligament of the palmar aponeurosis, and septum of Legueu and Juvara. The cord was attached deeply in the soft tissue confluence of the sagittal band, palmar plate, and interpalmar plate ligament. Involvement of the transverse ligament of the palmar aponeurosis and septa of Legueu and Juvara in Dupuytren's disease is rare. Understanding of the normal and pathologic fascial anatomy explains their simultaneous involvement and is necessary for complete ablation of the diseased tissue.     

Dupuytren's contracture of the fingers and its surgical treatment

Based upon clinical observations of patients, character of pathologico-anatomical alterations of palmar aponeurosis in Dupuytren's contracture the author distinguishes a typical and atypical forms of the disease and proposes a new method of dissection of the medial part of the palmar aponeurosis with altered and not-altered longitudinal bands of the distal part of aponeurosis with keeping intact the transverse fibres at the level of the metacarpophalangeal articulations.     

Immunohistochemical and immunologic changes in aponeurosis in Dupuytren's disease

Authors examined the aponeurosis of 23 patients with Dupuytren's contracture and of 5, formerly healthy persons, who died in consequence of accidents. It was found that the IgA and IgM content of the palmar aponeurosis is significantly elevated in Dupuytren's disease. The distribution of the immunglobulin containing cells and the fibronection localisation of the aponeurosis was also examined. On the basis of their examinations they think that the autoimmun mechanism may have a role in the development of Dupuytren's disease.     

Pathologic anatomy.

The typical case shows one or more thickened bands overlying the flexor tendons in the palm that connect with one another via the transverse palmar fascia. Vertical septae fix the bands securely to the underlying fascia and transverse metacarpal ligaments. These septae pass deep between the tendon and neurovascular tunnel. Bands running into the fingers represent thickening and fibrosis of the natatory ligaments. Typically, a central band continues into the finger, forks, and dissipates just distal to the PIP joint. This dissipation occurs with bifurcation of the central band into two thickened bundles that pass deep to the neurovascular bundle and attach to the flexor sheath of the middle phalanx. There are also thickenings of Grayson's ligaments that run from the central cord laterally and dorsally. Understanding the anatomy of the palmar aponeurosis is essential to the effective treatment of Dupuytren's contracture. Because the cause is unknown, treatment is best directed at anatomic deformities. Although not systemic or lethal, poorly treated Dupuytren's contracture can lead to significant morbidity and long-term disability. The palmar aponeurosis and its substructures are more than just passive barriers. They integrate hand parts and when pathologically fibrosed can contract joints, deform skin, and deviate neurovascular structures. The best treatments are recognition of the contracture, meticulous dissection, and local radical fasciectomy. Special attention is directed toward protecting spiralling neurovascular bundles. Difficult releases are enhanced by judicious release of checkreins, tendon sheath attachments, and disease on the radial side of the hand.     

手部屈曲挛缩畸形的修复

目的总结手部屈曲挛缩畸形的病因、诊断及手术治疗方法. 方法 1997年5月～2004年6月,对212例手部屈曲挛缩患者,采取切除瘢痕、彻底松解挛缩、植皮、Z字成形术或双V-Y或四边V-Y成形术、掌背动脉皮瓣移位或髂腹股沟皮瓣移位修复继发创面.其中男163例,女49例,年龄3～61岁.左手85例,右手54例,双手73例.挛缩部位:手指117例,手掌32例,手掌合并手指63例.畸形原因:烧伤及爆炸伤29例,掌腱膜挛缩127例,车祸及机器挤压伤31例,电击伤5例,术后不正确外固定14例,其它6例.病程2～24个月. 结果术后149例获随访4～30个月.1例因术后强行出院,手指远端坏死,行残端成形术;7例发生二次屈曲挛缩畸形,其中3例术后皮肤坏死瘢痕愈合,2例患儿因惧怕疼痛功能锻炼欠佳,2例断层皮片移植者皮片挛缩;其余患者疗效满意. 结论明确挛缩病因及程度,选择合适的手术时机,彻底松解挛缩,正确的修复方法及术后早期、有效的功能锻炼,是取得良好疗效的重要因素.     

Etiology of Dupuytren's contracture

Dupuytren's contracture is a connective tissue disorder characterized by contractile palmar aponeurosis leading to shortening and progressive digital flexion deformity. Various investigators have proposed many theories and documented several findings regarding the aetiology of Dupuytren's contracture. However, none of them explains the causes well enough. Most studies have found relationships between the disorder and manual labor, previous hand injures, genetic susceptibility, diabetes mellitus, epilepsy, high cholesterol level profile and intake of either alcohol or tobacco. However, according to others, the evidence on risk factors associated with certain lifestyles has been conflicting. This article reviews the most common theories regarding the aetiology of Dupuytren's contracture such as genetic, microinjury, immunological, toxic and ischaemic theories.     

Epidermal growth factor receptor (EGF-R) in Dupuytren's disease

The aim of this paper was to examine participation of the epidermal growth factor receptor (EGF-R) signal pathway in the pathogenesis of Dupuytren's disease. The study showed changes in the ratio of membrane EGF-R to its intracellular level during the different clinical stages of Dupuytren's contracture progression. Our observations of a high ratio of surface to intracellular EGF-R in the palmar aponeurosis of patients with second degree of Dupuytren's disease (Iselin's classification), which was significantly higher than this ratio in control palmar fascia (P=0.022), would suggest that EGF-R has a role in the involutional phase of the disease.