Dupuytren’s disease surgery

What is Dupuytren’s disease surgery?

Dupuytren’s disease is a condition in which fibrous layer of tissue underneath the skin of palm and fingers are affected. This disease leads to the thickening of the tissue leading to nodules, that could then progress to tightening of the fascia resulting in cords causing inward pulling of fingers towards the palm. When the condition progresses and starts interfering with hand function, then Dupuytren’s disease surgery becomes necessary. The main purpose of the surgery is to improve the function of the hand and decrease the contracture. It is performed to limit the effect of contracture by disrupting or completely removing them.

There are two types of surgery performed to treat the contractures-

  1. Fasciotomy- in this procedure, the cord is divided in the palm or finger with a needle or a small incision on the skin, but the cord is not removed. This procedure could be safely performed in pal, however the risks of nerve/tendon injury in finger joints is high. The procedure is usually done under local anaesthetic and the risks of the disease coming back are high when compared to fasciectomy. It’s usually performed as day surgery and for full recovery it can take upto one month.
  2. Segmental fasciectomy – Small segments of dupuytren’s cord are removed through one or more small incisions. In Simple dupuytrens disease with a 1-2 main cords, this procedure works well with minimal cuts in your skin. However, in complex disease with multiple cords, the procedure could be less effective. It’s usually performed as day surgery and for full recovery it can take upto one to two months.
  3. Regional fasciectomy – in this procedure, the entire abnormal cord is removed by making a zig-zag incision on the skin of the hand. The surgeons use loupes to identify nerves/blood vessels and separate the cord and excise them completely. The results are more predictable with good correction of deformity, fewer complications and lowest risks of recurrence in experienced hands. It’s usually performed as day surgery and for full recovery it can take upto 3months.
  4. Dermofasciectomy- this procedure is needed in some cases, where the skin is damaged too much. The skin and fascia are both removed and the skin is replaced by a skin graft. Its usually performed in patients who has recurrent disease or those with extensive disease (Dupuytren’s diathesis)
  5. COLLAGENASE (Xiapex) – A medicine is injected to dissolve the cord and the finger straightened a week after the injection. The risks of recurrence are high, however the recovery is quickest compared to other techniques.

 

What are the indications for the procedure?

  • Contracture of metacarpo-phalangeal joint (palm meets finger) of more than 300
  • Any contracture of interphalangeal joint (finger joints).
  • Contracture between thumb and index finger (1st web space) reducing the hand span
  • Severe, diffuse disease
  • Multiple joint involvements
  • Marked reduction in the hand function
  • Recurrences
  • Shortening of the ligaments
  • Fibrosis of structures like volar plate

 

What are the benefits?

The benefits of the surgery for Dupuytren’s disease are-

  • IMPROVEMENT IN HAND FUNCTION
  • Straightening of the fingers
  • Reduced deformity

 

What are the risks?

The risks of Dupuytren’s disease surgery are

  • Sloughing or necrosis of wound edge
  • Temporary numbness and tingling (neuropraxia) due to stretching of nerves.Injury to nerves and blood vessels (<5%)
  • Lack of blood supply to the fingers
  • Stiffness and swelling of the wound
  • Infection (<5%)
  • Flexion contracture
  • Recurrence
  • Scarring
  • Need for skin grafting
  • Stiffness and instability of finger
  • Complex Regional Pain Syndrome (<1%)

 

How should I prepare for the procedure?

  1. Before surgery, your surgeon will investigate your general condition through certain tests such as blood tests, electrocardiogram or chest X-ray to rule out any health risks. This helps to rule out any possible risks of surgery such as bleeding, heart diseases etc.
  2. It is advisable to inform your surgeon about any medications or supplements (esp. Blood thinners) you are taking. He may ask you to stop them before the surgery as they may complicate the operation.
  3. If you are a smoker, you should stop smoking at least 48 hours before the operation. Smoking increases the risk of chest and wound infection. It also affects your recovery process after the surgery by slowing it down. Some patients require help for household activities as many activities that require upper movement of the shoulder and other household activities such as bathing, dressing, laundry and cooking for few weeks nearly six weeks.
  4. Any infection in the body including common cold or a cough should be cleared up before the operation.
  5. You should also stop eating or drinking 8 hours before the operation.
  6. Positive attitude towards the operation and your condition are necessary for the success of the surgery. This will help you for better health benefits and faster recovery.

 

How is it performed?

  • The operation is conducted as a day case under local or general anaesthesia. Most patients are discharged on the same day.
  • The operation is performed under general anaesthesia or local anaesthesia (Block). In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation but he cannot feel whatever is happening in the surgical area. Your anaesthetist can select a combination of both local and general anaesthetic.
  • Positioning- the patient is positioned in the supine position and hand is centred on the hand table.
  • A tourniquet is tied around your upper arm to reduce blood loss during surgery.
  • Procedure- after anaesthesia, you are given antibiotics to protect you from any infection during and after the surgery. The incisions are made according to the type of surgery selected for the condition. In fasciotomy, a needle is used to cut the cord or a small cut is made on the skin and the cords cut with scalpel, the cords are not removed and they are just divided to straighten the fingers. In fasciectomy, the skin is cut in a zigzag manner along the natural creases of the hand and the affected cord and damaged tissues are removed. In some cases, the skin gets damaged and lost due to the cords, dermofasciectomy is done for this. In this procedure, the skin is removed with the affected cords. A skin graft is used to replace the skin. The skin is usually grafted from your upper arm or forearm. The wound is closed with thin non-absorbable sutures and the wound is left open to allow healing.
  • The surgical time for the operation is 1-3 hours depending on the complexity.

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery; some patients may remain in the hospital overnight. Patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • You will have a plaster (Plater of Paris – half cast) with the fingers in the corrected position for 10-14 days. The patient is reviewed in clinic around 2 weeks following the operation for wound check, removal of stitches and hand therapy.
  • The hand therapists will teach you exercises to prevent stiffness, regain the normal range of motion, and restore strength and function of the finger. Besides they will also apply a splint. Based on the severity of pre-op contracture the hand therapist/surgeon will advise you regarding the use of splint. You have to wear the splint during sleep at night to avoid contracture of the finger.
  • The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).

 

What are the results of the operation?

The outcome of the surgery is excellent with minimal serious complications (<1%). The outcome following this surgery depends on grade and severity of the contracture and adherence to handtherapy. The outcome is very predictable under the experience of the author.

 

When can I return to driving and work?

You can get back to work in 2-4 weeks if you have a desk job, however might take upto 6 weeks if your job involves physical work. You should be able to resume driving in 2-4 weeks. The above time line could vary based on the severity of the contracture and the treatment modality.  Your physician will be able to advise you.

Dupuytrens disease

  1. Severe Dupuytren’s contracture affecting all 5 fingers causing severe disability
  2. Post -surgery, the patient regained almost normal function back in his hand

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