Information for patients with Dupuytren's Disease.
Edited By: Thomas Trumble, M.D.
Last updated Wednesday, January 12, 2005
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Figure 2 - Examples of several different types of incisions used.
Incidence and risk factors
Types of surgery recommended
Surgery is the mainstay of treatment for Dupuytren's disease.
Surgery is indicated once the patient and surgeon agree that the
condition is causing significant problems for the patient, and that
these problems are likely to be improved by surgery. Sometimes only the
most affected fingers will be operated on. If several fingers are
severely affected, then all of these may be operated on.
Surgery for Dupuytren's contracture is called "fasciectomy" because
it involves the removal of the abnormal palmar fascia that causes the
flexion deformity. The abnormal fascia is sometimes called "Dupuytren's
tissue". Surgery is usually done on an outpatient basis which means
that the patient will go home the same day of surgery. It can be done
with the patient asleep (general anesthetic) or awake with the arm
"frozen" (local or regional anesthetic). The decision as to which type
of anesthetic to use is usually made by the patient and their surgeon
or anesthetist. During the operation the surgeon makes incisions in the
palm and the affected fingers. Several different types of incisions can
be used (Figure 2). The surgeon removes the abnormal Dupuytren's tissue
in order to correct the flexion deformity and allow the finger to
extend. It is not always possible to achieve full correction, depending
on which joint is affected, the severity of the deformity, and the
amount of time that the deformity has been present. Figures 3 and 4
show the appearance of hands after fasciectomy.
Who should consider palmar fasciectomy?
Initially, Dupuytren's disease is often observed for a period of
time. This is because it often does not significantly interfere with
hand function. The disease is not curable with surgical intervention
and often recurs after surgery (about 50% of the time). Therefore, it
is not preferable to undergo surgery unless the condition is causing a
significant problem with hand function or is causing persistent
discomfort. Some guidelines for when surgery is warranted include,
flexion contracture >30 degrees at the metacarpal phalangeal joint
(the first knuckle, closest to the wrist), progressive flexion
contracture at the proximal interphalangeal joint (the second knuckle),
and persistent pain. These guidelines are not followed rigidly, and
generally surgery is warranted when the patient and surgeon feel that
the condition is causing significant problems for the patient that are
likely to be improved by surgery.
What happens without surgery?
Often it is preferable to postpone surgery if the condition is not
severe enough to interfere with the patients day to day activities. The
condition may remain stable for long periods, in which case no surgery
is needed. In other cases the disease progresses more rapidly. It is
difficult to predict how quickly the disease will progress in each
affected patient.Surgical options
Several different operations have been described for Dupuytren's disease. The most widely accepted is called partial palmar fasciectomy,
in which the surgeon removes the abnormal Dpuytren's tissue from the
palm and the affected fingers. This can be done through a number of
different incisions depending on the surgeon's preference. At the end
of the operation all of the incisions may be sewn closed, or some may
be left open to allow drainage. Both are accepted methods.
Other approaches include: the removal of all of the fascia, whether it is involved or not (total palmar fasciectomy); simply cutting the Dupuytren's cords in the palm (palmar fasciotomy)
— a method associated with higher recurrence, but often useful in
patients severely debilitated by other conditions; collagenase
injections — an experimental approach described above that is currently
in clinical trials. Sometimes (though not commonly) skin is excised as
well, especially in very severe cases, and replaced by skin grafts
(thin pieces of skin taken from another area of the body and placed
onto the open areas of the palm).
Effectiveness
Most patients have an improvement in hand function after surgery for
Dupuytren's disease. This is related to an improved ability to
straighten, or extend the fingers, and decreased flexion contracture.
The amount of benefit that a patient experiences is difficult to
predict preoperatively but is related to the severity of the
contracture being corrected and the joint involved. In general,
contractures of the proximal interphalangeal joint (PIP) are more
difficult to correct. Also, long standing contractures are more
difficult to correct. The improved motion experienced by the patient
usually persists for several years though approximately 50% of patients
will have some degree of recurrence over a 5-10 year period after
surgery.Urgency
Surgery is not urgent and it is not dangerous to the patient's general
health to postpone surgery. In fact, surgery should not be undertaken
unless the contractures are causing significant impairment of the
patient's ability to perform activities related to work or recreation.
Occasionally surgery is undertaken to relieve the pain that is
sometimes associated with Dupuytren's nodules, or too facilitate
personal hygiene in debilitated patients with severe contactures.Risks
There are potential complications with any operation. In surgery for
Dupuytrens disease these include: scarring, infection, hematoma (a
collection of blood under the skin), skin necrosis (loss of skin due to
poor blood supply), recurrence of disease, finger stiffness requiring
physiotherapy, and injury to nerves and vessels. Nerve injury can cause
finger numbness which is usually temporary but can be permanent. Vessel
injury due to the accidental cutting of a vessel or stretching of
vessels when the affected finger is straightened can cause loss of the
entire finger. This has been reported in the medical literature but is
rare.Managing risk
If complications such as nerve or vessel injury occur during surgery,
and are recognized, they are repaired at that time. It is uncommon for
a nerve or vessel to be cut though this complication can occur. Vessels
can also be damaged by straightening the finger during surgery, causing
stretching of the vessels which have become shortened due to the
contracture. This can cause poor blood flow to the finger which usually
improves over several minutes of relaxing the finger and applying warm
sponges. When vessels are damaged the worst case scenario is loss of
the finger though this is very rare. Post operatively, if infection
occurs this is usually managed with antibiotics, either by mouth or
intravenously depending on the severity of the infection. Occasionally,
an infection may require return to the OR for drainage. If skin
necrosis occurs (death of an area of skin due to poor blood supply),
this is usually managed initially with observation and later removal of
the dead tissue. Often the resulting wound will heal in on its own with
dressing changes, or a skin graft may be required to achieve wound
closure. Hematoma (a collection of blood under the skin) is managed
with observation if the hematoma is small enough to absorb in a
reasonable amount of time. Larger hematomas require drainage to prevent
skin necrosis and infection. Recurrence of contracture is prevented
with physical therapy and splinting, though despite the best efforts
some degree of recurrence is fairly common.Surgery for Dupuytren's Disease at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington
If you are interested in making an appointment to discuss this procedure in Seattle, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-BONE (2663) to make an appointment. Our clinical center is located in Seattle Washington, USA
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