Dupuytren’s Contracture Release
Procedure: Dupuytren’s Contracture Release
Surgery Length: 1-3 hours
Anesthesia: General or Local with sedation
Where: Outpatient Hospital
Recovery: Hand therapy multiple times each week for several weeks after surgery; Pressure splint worn for the first 48-72 hours
Back to work: 4 -8 weeks
Full activities: 8 weeks
Risks: Scaring, bleeding, infection, reoccurrence of Dupuytren’s Contracture (rare); Non-take of skin grafts if needed (rare); possible blood vessel and nerve injury (rare)
Many surgical techniques are now available to relieve the discomfort and decreased agility caused by scar tissue build up in the palm and fingers the involves pulling the fingers into the palm.
Dupuytren’s contracture is a disease, which involves a thickening of the fibrous tissues of the palm and usually occurs over a period of years. The disease can also involve the arches of the feet and toes as well as the dorsum of the penis of males. This fibrous hardening of the penis causes painful intercourse and can ultimately require surgical therapy. Dupuytren’s diathesis, as it is sometimes called, is seen in patients who have ancestral origins to Celtic or Anglo-Saxon backgrounds. It is also seen in the Scandinavian and Mediterranean populations. Other than this, the diathesis is also seen in diabetic patients and is preponderantly seen in males. When it is seen in females, these women are usually postmenopausal. This is a familial tendency toward Dupuytren’s contracture, but is not a notable inheritable trait.
Patients with Dupuytren’s contracture often have minimal palmar bands, which cause them no distress. However, these bands can become further thickened. This thickening can make it uncomfortable to hold objects or pull the fingers into the palm preventing the patient from straightening his fingers. This situation is most distressful in both work and play and an embarrassment for many patients when they open their palm to shake hands.
It is felt by some that this disease can be treated by Vitamin E therapy. However, in most cases surgical intervention is required for Dupuytren’s of the penis, hand, and in many cases the foot.
The most commonly treated Dupuytren’s entity is the hand. This ultimately necessitates, when function is compromised in the hand, a fasciectomy. This is an operation with an incision in the palm and possibly up the finger in a zigzag like manner. Subsequently the scar tissue is removed. Oftentimes this is difficult owing to involvement of the disease with the blood vessels, nerves, and tendons that go to the fingers and into the palm. Despite careful dissection, sometimes these structures are injured in the course of dissection. There is also a problem that the overlying skin in the palm has been thinned thought the time of the disease and there is compromised blood supply. When the blood supply is poor there may be some loss of skin or a necessity for skin grafting, either at the time of surgery or subsequently if there is loss of tissue. Nicotine compromises the blood supple to the skin. In order to prevent this and subsequent loss of skin, patients are told not to smoke or chew Nicoret gum for two weeks prior to, and the week after the surgery. Diabetics and older patients have poorer circulation and a greater problem with wound healing and possible skin loss.
As with any operative procedure, bleeding and infection can be a problem although this is usually not a great one. Since Vitamin E and Aspirin products inhibit clotting, we demand that patients not take these medications for two weeks prior to their surgery. Patients also have the problem of scarring from the incisions but these usually heal quite satisfactorily over a period of time. Dupuytren’s may reoccur despite such aggressive therapy. In such instances, the only treatment of choice is to return to re-excision of this tissue and then placement of a full thickness skin graft taken from the groin or the thigh area into the palm and/or fingers. There is some chance of non-take of the skin graft necessitating another skin graft. Also, there will be some scarring from the donor site chosen for the graft.
A more conservative or timesaving technique with respect to Dupuytren’s of the hand has been the use of a fasciotomy. This is an office procedure where the hand is put to sleep and small incisions are made in the palm with a small zigzag incision. The offending band, which is bringing down the finger(s) is incised, but not totally excised. This nicking or breaking up the band may be done at one or more locations. This technique is often used preceding a definitive total fasciectomy as it allows for early stretching of the skin and improvement of the blood supply to the skin. In patients who do not wish to have the prolonged recovery period from a total palmar fasciectomy, it allows an easy out improvement in their situation, which in some cases can be permanent. However, there is a propensity for the Dupuytren’s diathesis to recur between each of these little nicks along the band, and subsequently cause the return of the finger into the palm.
The previously mentioned palmar fasciectomy is an outpatient procedure, which is done under regional or general anesthesia at the hospital. It entails a procedure, which may last two or more hours and requires insertion of suction drains into the hand. The hand, after surgery, is dressed in a pressure type splint with small pressure drains exiting and connected to vacuum tubes. These tubes are changed by a member of the family in a frequent basis after surgery. The patient maintains the pressure splint for 48 to 72 hours. Removal of the drains follows usually within one week. An Ace wrap dressing is then used to allow for warm soap and water soaks of the hand. Hand exercises with a trained therapist will commence with a week of the surgery, and may be required for two months after the operation. The more extensive procedure of reconstruction for a palmar fasciectomy is definitely indicated in the younger patient or in the older healthy patient. Besides considering health and rigorousness of the procedure and follow-up therapy, one must also consider that this disease may be insidious and recur. The patient may require a repeat procedure along with the use of a skin graft.