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Dupuytren's

The disease was first described in 1831 by Baron Gauillaume Dupuytren, a French Surgeon. He described 'permanent retraction of the fingers' attributed to tightness of the palmar fascia. Dupuytren contracture is a progressive disease involving thickening of the superficial tissues in the palm of the hand (called the palmar fascia) which extends up all four fingers and thumb. Initially the disease starts with nodules in the palm of the hand, over the base of the finger which can be tender. This tenderness abates and essentially Dupuytren's is a painless condition. As the tissues thicken they also contract, a little bit like a scab on the back of a hand. As they contract the finger is gradually drawn in towards the palm. The fingers most frequently involved are the ring and little fingers, followed by the middle finger and the thumb. Involvement of the index finger is infrequent, although it can occur. The disease can also give lumps over the back of the hand over the back of the proximal interphalangeal joint (PIPJ). On average Mr Field performs 50 Dupuytren fasciectomies per year.

ANAESTHETIC

General or regional anaesthetic.

OPERATIVE PROCEDURE

  1. Percutaneous Fasciotomy In certain contractures which involve the MCPJ only and a band covering down the palm it are feasible to release the contracture under local anaesthetic using the cutting edge of a needle as a blade.
  2. Surgical Release - this involves the removing of the tight band of tissue and it called a fasciectomy. The wound is closed in zigzag fashion. Sometimes a skin graft is taken from the forearm (derma fasciectomy).
Surgical release.
An incision straight down the finger is performed. This will be closed up by means of (Z-plasty's). These brake up the straight line of the incision, generally across the first bone of the finger and perhaps a transverse or "giving" incision, in the palm through which a drain may be placed. Essentially this surgery involves raising the skin flaps, identifying the nerves and blood vessels that go down either side of the finger and avoiding them and taking out the Dupuytren's tissue (fasciectomy) The wound is generally closed with nylon sutures.

POST OPERATIVELY

A splint is put on the hand to keep the fingers straight, the arm elevated over night. The wound is then observed the next day (this generally involves an overnight stay). The skin flaps are observed for vascularity, and the drains are removed. Physiotherapy and splinting will commence the first day post-op and the splint will be maintained at night for three months and also during the day in between exercise sessions. As soon as it is feasible to get the fingers to roll up into the palm (making a fist) then the splint can be removed during the day and just maintained at night.

Return to work

It is likely that the patient will require six weeks off work at least.

COMPLICATIONS

  1. Digital nerve damage - There are nerves that travel up each side of the finger and these are in jeopardy during the surgery. The incidence of severing one of these nerves is 1%. If it does occur the nerve is repaired at the time of surgery. The whole object of this Dupuytren's surgery is to identify these nerves.
  2. Infection - Infection occurs in between 1% and 5% of cases. Generally it is easy to treat with antibiotics when identified.
  3. Flap necrosis - Sometimes the zigzag shaped skin flaps die at the tips. This involves not real problem, it just means that the wound takes a little bit longer to heal.
  4. Incomplete correction - If there is a significant contracture at the proximal interphalangeal joint (90° or more) it is unlikely that that joint will be completely straight at the end of the procedure. It is much more likely for metacarpophalangeal joint contractures to be fully corrected than PIPJ contractures.
  5. Recurrence - Recurrence of Dupuytren's is very common. A percentage of recurrence is 40% in the little finger and 25% in the rest of the hand.
  6. CRPS - there is a probably a 1-5% chance of developing this conditions which can give symptoms that are worse than the previous condition.