Ortho-Preferred

Surgical Treatment of Dupuytren's Contracture


- Surgical Indications:
     - MCP contracture greater than 30 deg;
     - PIP joint: any significant contracture (more than 20);
     - precautions:
            - take care to note any sluggish filling of the digital vessels (Allen's test);
            - women may have higher incidence of postoperative stiffness & RSD;
                   - because women have flare reaction if they undergo a carpal tunnel release when the palmar fascia is exised, it may be prudent to stage these procedures;
            - patients should clearly understand that results of surgery are variable and recurrence is not uncommon;
                   - MP joints can more predictably be corrected than PIP joints;
            - consider use of a digit wigit to gain PIP extension prior to formal subtotal fasciectomy;


- Choice of Incisions:


- Surgical Options:
     - total palmar fasciectomy:
             - mentioned to be condemned because of the frequent profound postoperative morbidity;
     - subtotal palmar fascietomy (preferred technique)
     - local fasciectomy:
             - for debilitaed patients, MPJ contracture, & will improve the PIP joint;
             - excise a short segment of disease tissue;
             - limited subQ palmar fasciotomy is a temporizing partial solution that is applicable to patients who are unsuitable for anesthesia;
             - recurrence may occur in up to 66% of patients;
     - open palm technique from McCash (1964)
              - The open palm technique in Dupuytren's contracture
     - dermofasciectomy
             - (Hueston) may be required for recurrent cases;
             - involves excision of overlying skin as well as fascia;
             - attempt to save skin over the flexor tendons;
             - requires FTSG for coverage;
             - reference:
                   - Dermofascietomy for Dupuytren's disease.  
     - full thickness skin grafting:
             - indicated for patients w/ risk factors for recurrence (such as, previous surgerical release, bilateral or ectopic disease, ect);
                   - also indicated for patients w/ dippled contracted skin, which may be excised (rather than incised in the usual manner);
             - requires that tourniquet be deflated and hemostasis be achieved;
             - consider temporary application of thrombin to defect during graft harvest;
             - pt must understand that hand must be kept elevated post op;
             - sutures and dressings are removed at 3 weeks weeks;
             - ref: Does a 'firebreak' full-thickness skin graft prevent recurrence after surgery for Dupuytren's contracture?: a prospective, randomised trial.
     - fasciotomy
             - original surgery preanesthesia and preantibiotics,;
             - simple subQ fasciotomy should never be attempted in digits, where the neurovascular elements may be easily injured;
             - subcutaneous fasciotomy is no longer needed;
             - refs:
                    - Treatment of Dupuytren's contracture. Long-term results after fasciotomy and fascial excision.
                    - The long term results of closed palmar fasciotomy in the management of Dupuytren's contracture
                    - Dupuytren's contracture - the role of fasciotomy
     - misc:
             - note that it is easier to prevent digital spasm than to manage it;
             - consider irrigating vessels prophylactically during the case w/ lidocain or papaverine;


- Post Op:
      - carefully fashioned bulky hand dressing is manditory;
      - the bulky hand dressing needs to have enough gauze placed in the palm so that the AP diameter exceeds the width of the metacarpals;
             - this allows for more efficient compression against the wound;
      - pain in the post operative period must alert the surgeon of a possible post operative hematoma;
      - some advocate several days of immobilization of hand w/ slight wrist extension along w/ MP flexion and slight PIP flexion before early mobilization is started;
             - MP and PIP extension may place extensive tension on the wound, which can lead to necrosis;
             - it is essential to avoid postoperative stiffness;
      - after several days, consider initiation of active ROM and/or extension splinting at night;


- Complications:
     - recurrent hematoma
     - skin loss
     - infection (treated with early debridment) - use of K wires is thought to promote infection;
     - joint stiffness
     - RSD:
           - look for swelling, pain, stiffness, and discoloration;
           - causes:
                 - neuroma formation
                 - digital nerve scarring at the incision site;
                 - excessive wound tension;
                 - secondary carpal tunnel syndrome (from edema)
                 - secondary trigger finger;
     - recurrent disease:
           - risk factors:
                 - Northern European ancestory;
                 - ectopic disease and/or bilateral disease;
                 - multiple digit involvement



Surgical alternatives in Dupuytren's contracture.

Wound complications in the surgical management of Dupuytren's contracture: a comparison of operative incisions.

Dermofasciectomy in the management of Dupuytren's disease 



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, May 30, 2012 3:33 pm