Dupuytrens Contracture Surgery

Dupuytren surgery has a goal of limiting the restricted movement of the afflicted fingers by removing or separating the tough bands and cords of diseased fascia in the palm. It is readily admitted that Dupuytren contracture surgery does not cure the disease; it is merely meant to prevent progression of the disease and to sever the debilitating joint contractures.

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Indications for Dupuytrens Contracture Surgery

Surgery is indicated when the extent of MCP joint contracture is 30° or more. There is good statistical response from surgery to this particular joint, and there is not great recurrence of a contracture – unlike other areas.

Dupuytren contracture of the PIP (proximal interphalangeal) joint is measured here at 30° of flexion deformity,
the standard point at which surgery is often recommended

Surgery for a PIP joint contracture does not have the same prognosis as for MCP involvement. Usually removal or incising the diseased fascia does not do much to correct the joint contracture, particularly when the condition has been present for a long while. For this reason the surgeon often will perform this Dupuytren contracture surgery as soon as PIP contractures are found.

Surgery for loss of normal hand function and partial disability is a purely subjective matter that may be an indication for surgery. Dupuytrens contracture surgery might be performed if the patient clearly understands the nature of the disease process and accepts the 20% potential for exacerbation of pain and further loss of function as a result of the operation.

Surgery for Dupuytren lumps on palms of  both hands is done to the worse or dominant hand should be first. After allowing for complete recovery and rehabilitation, usually after two months, then surgery with the other hand can be performed.

Dupuytren Contracture Surgery Options

Fasciotomy involves incising (surgically separating without removal) the involved fascia. This procedure may provide short-term relief, but is also associated with a very high recurrence rate. This procedure may correct an MCP joint contracture but almost certainly will not correct a PIP joint deformity. This procedure is reserved for the elderly or debilitated surgical candidate who is unable to tolerate a more lengthy or extensive procedure.

Extensive fasciectomy involves removing as much fascia as possible from the disease area of the palm, including that which is grossly normal. Currently, this procedure is not commonly performed because of the increased associated morbidity including hematoma risk and prolonged postoperative edema and stiffness.

Dermofasciectomy removes the diseased fascia as well as the overlying skin, with a full-thickness skin graft placed over the surgical wound. This technique has a recurrence rate that is quite low. Because of the radical nature of this procedure, it is usually reserved for patients with recurrent or severe disease.

Regional fasciectomy is a technique that removes grossly diseased fascia. Although it has clearly been shown that the disease process extends into apparently normal palmar fascia, this approach has proven successful in correcting MCP joint contractures and some PIP joint contractures, and carries an acceptably low morbidity rate.

Dupuytrens contracture surgery should be avoided if other less invasive methods
of treatment have not first been investigated, since 20% of surgeries result
in “complications” (see explanation at bottom of article)

Incisions vary and may be transverse, zigzag, or longitudinal, depending on the region involved. It is necessary to first elevate the skin off the underlying diseased palmar fascia in order to identify all the neurovascular bundles that may be in jeopardy during dissection and subsequent surgical removal. Each involved finger has two bundles of blood vessels and nerves that must be identified. These neurovascular bundles may be displaced, distorted, or pressed upon by the contraction and thickening of the palmar fascia. Usually, a line of separation can be created before dissection between the diseased palmar fascia and neurovascular bundles to prevent any accidental injury to the blood vessels and nerves to each finger. The surgeon must make immediate repair to any blood vessel or nerve that is accidentally injured using a surgical microscope.

After the full location and course of each neurovascular bundle is identified and cut away from the diseased palmar fascia, the diseased fascia is then removed. Any contracture deformity of the MCP or PIP joints are addressed at this time. If these surgical maneuvers fail to improve the flexed state of the involved fingers, then the surgeon will closed the hand wounds and proceed with an aggressive course of postoperative splinting and hand therapy to improve function of those fingers.

Dupuytrens Contracture Surgery Complications

Post-operative complications include excessive inflammation, hematoma, ischemic skin necrosis, infection, granuloma formation, transient paresthesia, additional scar contracture worse than before the surgery, persistent proximal interphalangeal (PIP) flexion contracture worse than before the surgery, distal interphalangeal (DIP) hyperextension deformity worse than before the surgery, joint stiffness worse than before the surgery, poor flexion and grip strength worse than before the surgery, pain worse than before the surgery, and reflex sympathetic dystrophy (RSD). Comparing surgical incisions, skin necrosis, hematoma and pain problems are more likely with zig-zag exposures, while delayed healing and nerve injuries were reported more often after transverse incisions.

Overall Dupuytrens contracture surgery may actually aggravate the process, and patients may be worse off after surgery than they were before. Complication rates following surgery have been reported in the range of 17% to 41%.  Complications are nearly twice as common following repeat surgery than for primary surgery.

From the following it is obvious that Dupuytrens contracture surgery is a delicate and complicated procedure. It is the Dupuytren treatment philosphy of DCI that no one should lightly decide to undergo this type of surgery unless other, more conservative and potentially less harmful, avenues of care have been completely explored. DCI does not object to the use of surgery in non-responsive cases of Dupuytrens contracture; DCI does pose a question about the appropriateness of Dupuytrens contracture surgery before other conservative and non-invasive measures are first used to determine if the patient would indeed heal under the influence of Alternative Medicine therapy. For additional information, click Dupuytrens Alternative Treatment.

The normal and full use of your hand or hands can be taken from you by Dupuytrens contracture. Do all that you can, as early as you can, to allow your body the best opportunity to reverse this problem.

For ideas and suggestions to organize an effective Alternative Medicine treatment plan, click Create Dupuytrens Treatment Plan