Surgery for Dupuytren's Contracture

Introduction

Dupuytren’s disease is a result of abnormal thickening with formation of nodules and cords, of the tough fibrous tissue (palmar fascia) in the palm. The contraction of this abnormal tissue leads to the fingers drawing in towards the hand. It is sometimes called the “Viking disease” as it is prevalent in those of Scandinavian and Celtic origins. It generally affects people over the age of 50 and is gradually progressive. There are no known measures to prevent the disease but smoking is a definite risk factor.

This condition was described by a French Physician called Guillaume Dupuytren in the 19th century.

Indications for surgery

Surgery is recommended once the condition interferes with your daily activities and you cannot place your hand flat on the table. The surgery involves removing the diseased fascia and so allowing the fingers to straighten. The results of surgery may last many years. However, surgery doesn’t cure the disease permanently and it may well occur as time goes by. Those who require surgery at a young age tend to have a recurrence earlier.

A fasciectomy (removal of abnormal fibrous tissue) is an effective treatment for Dupuytrens’s Disease. If the palm has been severely contracted for a long time or there has been previous surgery, skin grafting may be required. Dupuytren’s surgery is usually performed as a day procedure.

Pre-operative Instructions

By the time the GP refers the patient to Dr Lane, the diagnosis is evident and the disease has impacted daily activity. Dr Lane will provide comprehensive information about your upcoming procedure including surgical risks and after care.

Ant-inflammatory drugs such as Feldene, Naprosyn, Brufen, Ibuprofen, Indocid, Voltaren, Mobic and Celebrex should be stopped 5 days before surgery. These drugs increase the risk of bleeding. Aspirin and other blood thinning drug use should be discussed with Dr Lane as this would depend on the patients underlying medical condition. The hand to be operated on should be free of cuts, abrasions and sores as this would increase the risk of infection. If there is damage to the skin in the area that has to be operated on, then it is likely that the operation will be postponed.

Dupuytren’s hand surgery is usually performed as day procedure. You will be given clear instructions from the reception staff when to attend the hospital depending on your surgery time. Please take your Medicare, DVA or Private Health care cards to the day Hospital Admissions Unit.

Prior to surgery:

  • You will be admitted by the duty nurse and baseline observations taken.
  • Theatre gown given to wear.
  • The hand will be inspected, washed with anti-septic solution and covered with a sterile drape by the nursing staff.
  • You will be given TED stockings to wear in theatre to reduce the risk of deep venous thrombosis after surgery.
  • The nursing staff will take you to the theatre complex and then into the anaesthetic bay where you will meet your anaesthetist and Dr Lane. Surgery is usually performed under a general anaesthetic.

Procedure

Once in theatre and you are asleep, a high arm tourniquet is applied to provide a blood less field in which to operate. The arm and hand are then prepped with an anti-septic solution and patient covered with sterile drapes with a window for the operating site.

Surgery may take 1 to 3 hours depending on the severity and extent of contractions. Zig-Zag incisions are made over the hand or/+ fingers and the diseased tissue excised. If the contractions are severe or previous surgery, it may be necessary to have skin grafting but this is avoided unless absolutely necessary. Every effort is made to identify and protect underlying vessel and nerves during surgery.

After surgery is complete, the skin is closed with sutures and the wound infiltrated with local anaesthetic to aid post-operative pain relief. The wound is then covered with primapore, and dressed with wool and crepe bandage. The hand is splinted in optimal position. A high arm sling applied.

After surgery, you will be taken to the recovery ward and once adequately awake, observations stable and able to eat and drink, you will be ready for discharge home. It is important that someone takes you home. The anaesthetist will provide you with a script for pain relief.

Post-operative Instructions

It is important to keep dressings clean and dry until reviewed by Dr Lane in 12 – 14 days. Keep hand in high arm sling as able and on pillow in bed at night as this will help reduce the swelling. Please contact Dr Lane if excessive bleeding and soiling to dressings.

At the first post-operative visit, your sutures will be removed and wound inspected by Dr Lane. Further dressings will be applied for the next 4 days. You will be referred to a hand therapist for splinting, mobilisation and scar management.

The recovery period following surgical fasciectomy is a period of weeks. If the incisions heal you should be able to return to light duties at 2- 3 weeks and 6 weeks for heavy duties.

Risks

General risks associated with Anaesthetic (Rare)

  • Death.
  • Myocardial Infarction.
  • Stroke.
  • Pneumonia.
  • Deep venous thrombosis.

Local risks (uncommon)

  • Infection with wound breakdown.
  • Bleeding and haematoma formation.
  • If single digital artery injured, then the patient may notice cold intolerance. If both digital arteries are injured then amputation of finger maybe necessary.
  • Nerve injury will result in numbness to the affected area. This numbness may recover over time especially if nerve has been only stretched during procedure.
  • Scarring.
  • Nerve pain called complex regional nerve syndrome.
  • Stiffness of fingers.

Patients who are smokers, diabetic and have multiple pre-existing medical conditions are at a higher risk of complications.