Dupuytren hand surgery can be dangerous: Facts you should know

Risks of hand surgery as a limited Dupuytren treatment

Any type of surgery presents risks and can produce unintended side effects.  Unanticipated complications following open hand surgery for Dupuytren contracture has been reported in 17% to 41% of cases.  Further, these side effects are nearly twice as likely to occur for repeat surgery when Dupuytren’s contracture recurs after a first surgery.

This article will focus on the potential complications of Dupuytren’s contracture surgery, specifically a category called palmar fasciectomy.

Avoid Dupuytren hand surgery with Alternative Medicine

Anyone considering Dupuytren surgery should be encouraged to know that by natural Dupuytren treatment it might be possible to avoid a hand operation.

Medical research by Messina, Loos, and Bulstrod report successful outcomes for Dupuytren contracture after using the non-surgical methods of massage, exercise and traction, yet their work receives little attention.  Research interest has always been primarily directed toward high profile profitable surgery and drug therapies. Alternative medicine is not a high profit way to treat hand contracture although the Dupuytren Contracture Institute has been helping people since 2002 deal with their hand problems.

Not all people respond to Alternative Medicine, just as not all people respond well to drugs and surgery.  However, the advantage with using simple and low cost natural therapies and remedies is that when they do successfully assist the body to recover from a health problem, the need for drugs or surgery is lowered or eliminated.  The idea of attempting a short therapeutic trial of natural remedies first, rather than last, takes advantage of conservative ideas at the beginning of care.  Later, if Alternative Medicine fails to assist the healing response then more aggressive drugs or surgery can still be used.

The Dupuytren Contracture Institute is not against hand surgery for Dupuytrens contracture.  Obviously there is a need for surgery when natural methods have been unsuccessful.

The risk and limitation of Dupuytren surgery should be considered not only because of the potential permanent consequences (permanent pain and numbness, reduced finger movement, reduced hand strength) that can occur, but also because surgery is not the only option to reduce palm lumps and finger cords.

Hand surgery is not final

Two primary cautions should be kept in mind before submitting to surgery for the hands: First, even when Dupuytren’s surgery is done well by a skilled surgeon, unintended consequences occur that no one can anticipate or explain.  Second, Dupuytren surgery is well known to   stimulate the recurrence of additional nodule and cord formation in the palm after removal – sometimes as soon as in a single year, often three or four years.  Since Dupuytren contracture is famous for recurrence within a few years after surgery, anyone thinking about a surgical option should realize that once the first surgery is done it is just a matter of time before the next surgery will have to be done.  The typical pattern is that with each Dupuytren surgery the next recurrence of hand nodules will be a little faster than the last.

The only way to know for sure if Alternative Medicine will stimulate the natural healing process is to use a solid round of natural remedies for a month or two to determine if positive changes occur.  If successful, then the patient should consult with her physician to learn if surgery can be avoided.  If it does not help, then surgery can proceed knowing any potential risk is justified by the lack of progress with conservative methods. .

To learn about Alternative Medicine self-management, please see Different Way of Looking at Dupuytren Contracture Treatment

 

 

 

My hands got worse after Dupuytren’s surgery, what can I do?

Strategy to avoid risks of Dupuytren hand surgery   

All surgery has risks. Even the most simple and direct surgery can result in an unexpected bad reaction.  These can occur due to human error and judgment issues, or simply for reasons that are unavoidable and totally unexpected.

Complications after open hand surgery for Dupuytren contracture  (palmar fasciectomy) is variously reported to occur in 17% to 41% of cases, clearly higher than for many other types of surgery.  While the side effect and complication rate for needle aponeurotomy (palmar fasciotomy) is much lower at 2 to 4%, this must be weighed against its much faster Dupuytren recurrence rate and the need for additional palmar fasciotomy surgery sooner and more often.

It is important to understand that chances for adverse reactions after either of these two types of hand operations are at least doubled when performed as a second or third Dupuytren surgery.  Simply stated:  1. The more often palmar fasciectomy or palmar fasciotomy are performed the riskier each succeeding surgery becomes, and 2. repeat hand surgery is performed because of the high rate of recurrence of Dupuytren contracture after surgery.  With each surgery normal anatomy changes and less useable tissue remains.  Sooner or later so little tissue is left for the next surgeon to use, until no more hand surgery can be done.

Avoid or delay palmar fasciectomy surgery with Alternative Medicine

Those considering a second or third Dupuytren surgery after a needle aponeurotomy (palmar fasciotomy) or open hand surgery (palmar fasciectomy), should be interested to consider natural Dupuytren treatment as a possible way to postpone or avoid another hand surgery.

To learn about Alternative Medicine self-management, please see Different Way of Looking at Dupuytren Contracture Treatment

Medical researchers, Loos, Messina, and Bulstrod report successful outcomes of Dupuytren treatment using massage, exercise and traction, all without surgery.  Even so, not much interest is given to their work because research funding is always focused on high profile surgery and drug therapies. Natural therapies of Alternative Medicine are not a high profit way to treat Dupuytren contracture, although the Dupuytren Contracture Institute has been providing insight and assistance since 2002 to help people deal with their hand problems.

Not all people respond well to drugs and surgery, and not everyone responds to Alternative Medicine.  And just as no one in the practice of medicine can say with certainty that any drug or surgery will be successful, no guarantee can be offered that non-drug and non-surgical natural methods will assist your recovery. Even so, the advantage of using a simple and low cost Alternative Medicine approach is that when it does successfully assist the body to recover from a health problem, the need for drugs and surgery is lowered, delayed or eliminated.   Another major advantage is the well known low risk of natural therapy compared to drugs and surgery.

For those who have never had Dupuytren surgery, the conservative option is to undergo a short therapeutic trial of care with natural remedies first – rather than last – to possibly avoid hand surgery.  For those who have had one or two Dupuytren operations, the conservative option is still open but with reduced expectation.  In these cases the body has less normal tissue to work with; results cannot be as good as when surgery was never performed.

In the experience of the Dupuytren Contracture Institute working with those who have had one hand operation, it is possible to eliminate the need for a second surgery and cause doctors to change their recommendation for the need of a second surgery.  With a brief trial of Alternative Medicine treatment it is possible to make positive tissue change and either avoid or delay the need for surgery.

Rapid recurrence of Dupuytren contracture means more hand surgery later

Many who write on Dupuytren’s forums express the cavalier notion that they are willing to submit to needle aponeurotomy every few years even though recurrence is more rapid with this type of less invasive hand surgery.  They explain that they prefer NA because recovery is so rapid or they can use their hands in a few days with no rehabilitation. They fail to calculate that this does not necessarily happen each time needle aponeurotomy is done. They do not consider the risk of an adverse reaction increases with each surgery, preventing this approach to be used indefinitely.

For those who already have had one Dupuytren’s hand surgery and want to avoid another, this article presents possible avoidance options as well as the potential complications and risks of palmar fasciectomy, also known as Dupuytren’s contracture open hand surgery.

Bad reaction after Dupuytren’s surgery, what is next?

The idea that it is possible to correct a bad surgery with another surgery must be examined very closely.  While there must be cases where this works out well for the patient, extreme caution must be used to assure a bad situation is not made worse by additional irreversible tissue changes of compounded surgery.

First, get a second surgical opinion but not for the reason many people think. Patients typically approach a second medical opinion only to see if it agrees with the first.  This is often just another way of allowing two doctors to make a decision for a patient. The best use of a second doctor’s opinion is to receive additional medical information and a different view point to round out the thinking of the patient.  Both medical opinions should supply information to help the patient decide the next step to take.  It is the patient who must ultimately decide the best course of action to take to return to health.  When the patient does not feel capable of making that kind of decision, it is the fault of the doctor who has not provided adequate information to the patient.  Find another doctor who will talk to you and explain things in such a way that you can make this decision!

In no way is it suggested that a layperson can know more about the practice of medicine than the doctor.  Even so, the layperson must ask questions and receive answers from at least two doctors so she is able to make an informed and intelligent decision about her care – not the doctor.  A lazy patient does not get the best care.

It is the responsibility of the patient to assure that a second surgery is the best step to take – as it might be. Too often patients rely solely on the judgment of the first doctor they encounter to make important decisions for them.  This is not wise.

If you do not like the thought of additional Dupuytren surgery, for whatever reason, you can consider attempting Alternative Medicine treatment for a month or two or more to learn if your body is capable of reversing the abnormal hand contracture.  If it helps your situation and surgery is no longer indicated, look what you have gained.  If it does not help, you can have surgery knowing you have not been hasty, you have used conservative measures appropriately, and whatever reaction occurs from a second surgery was indeed unavoidable because less aggressive measures did not help you.

Suggestions to determine if your body is capable of changing the soft tissue contractures in the palm and fingers:

1. Learn about your Dupuytren problem from a different standpoint.  You were told you needed hand surgery by the MD who gave you the diagnosis of Dupuytren contracture.  Almost all internet information about Dupuytrens promotes surgery.  Go to the home page of the Dupuytren Contracture Institute for holistic information about day-to-day treatment. The information found on this website is unique because we present the idea that not all Dupuytrens needs surgery.

2.  Determine the most aggressive Dupuytren therapy plan you are comfortable following.  For best results do all that you can to help yourself.  Consider using what is called the “Large (Best) Plan” for personal treatment.  The “Medium (Better) Plan” is the most popular of the DCI plans.  The “Small (Good) Plan” is also well designed.  These three plans are found at the top of the page at Dupuytren treatment plans.   Any plan can be modified by subtracting or adding to suit your personal Dupuytren contracture treatment philosophy.  These plans are only examples of how to approach this problem, and have helped hundreds of people over the years.

3. Stop feeling discouraged. Read the Dupuytren Hand Bump Forum.  Get educated, motivated, and reminded that everyday around the world there are people who are actually beating their Dupuytren problem following the Alternative Medicine methods of the Dupuytren Contracture Institute.

Complications of open hand Dupuytren surgery (palmar fasciectomy)

No one, not even a surgeon, can predict the side effects and complications of a particular surgery – and that is the problem.  While many patients, even a majority, receive a palmar fasciectomy without an adverse reaction and no post-surgical complication at all, there are those who are worse after surgery.  The number or percent of adverse surgical cases is not important if you are one of the unlucky patients whose outcome is poor. The only bad outcome that matters is your own.

Keith Denkler, MD, in 2010 wrote, “Surgical Complications Associated with Fasciectomy for Dupuytren’s Disease: A 20-Year Review of the English Literature.”   His final comments,
“In conclusion, results of this study underscore the importance of
treating Dupuytren’s as an incurable genetic disease understanding that
surgical excision, fasciectomy, has a high rate of major and minor
complications. Surgeons must understand that while fasciectomy for
Dupuytren’s does offer a chance at long-term ‘straight’ fingers, there is
a high cost in terms of numbers of complications that are borne by the
patient.”

Because the hand is a highly complex and densely packed machine with practically no space separating very delicate nerves, blood vessels, muscles, ligaments, tendons, and fascia, the patient must carefully select the best surgeon for the best hand operation outcome.

The Dupuytren Contracture Institute is not against hand surgery.  DCI only suggests it is a prudent step to first try Alternative Medicine to learn if their Dupuytren soft tissue problem is partially or completely reversible, thus making surgery unnecessary.  If the need for Dupuytren hand surgery remains after natural methods has been unsuccessful, find the best surgeon possible.

Can Dupuytren contracture recur after I have hand surgery?

Recurrence of Dupuytren contracture is common and impossible to predict

In general, Dupuytren contracture recurrence means that is spite of hand surgery, the shortened, thickened tissue appears to return to the area of previous surgery, but actually is a continuation of the extension or progression of the disease into tissue previously unaffected.  Many surgeons openly speculate that Dupuytren contracture surgery accelerates the rate and extent of the disease progression.

In broad terms, the rate of Dupuytren’s recurrence after needle aponeurotomy (palmar fasciotomy) is considerably higher than for traditional open hand surgery (palmar fasciectomy).

Avoid surgery if possible with natural Dupuytren treatment

Any type of hand surgery done to release the contractures of Dupuytren disease can eventually result in the return of more contractures.  This recurrence if followed by another hand surgery can result in the return of more contractures eventually.  While this cycle of surgery and reappearance of more contractures proceeds, the patient is exposed to the potential risks of hand surgery each time it is done: permanent numbness, reduced finger movement, reduced hand strength, reduced sensations and pain.

To avoid this cycle the patient should consider the use of a brief therapeutic trial of Alternative Medicine as a conservative and essentially risk free option that could make surgery unnecessary.

Dupuytren’s surgery, even when done well, can have bad unintended consequences as well as stimulate the recurrence of additional nodule and cord formation in the palm.  Since 2002 this website has suggested that anyone with Dupuytren contracture should first consider conservative treatment options before attempting irreversible surgery.  To learn about Alternative Medicine self-management, please see Different Way of Looking at Dupuytren Contracture Treatment

What is Dupuytren contracture recurrence?

The wide range of recurrence rates represent only gross estimates because there is no formally accepted definition of this term, so what characterizes a reappearance of Dupuytren contracture varies from one study or doctor to the next.  Recurrence of Dupuytren contracture can be:

  1. A finger or hand that received a prior Dupuytren surgery had to be operated on again for any one of a variety of reasons.
  2. The condition of a finger or hand worsened after hand surgery, without evidence of even initial improvement.  Sometimes the worsening is determined to be any degree of flexion deformity greater than prior to surgery, and sometimes must be a 5-10 degree increase.
  3. The condition of a finger or hand was initially good after Dupuytren surgery, but after time some degree of finger flexion returned to that finger or hand.  Sometimes the return is determined to be any degree of flexion deformity greater than the level of correction initially provided after surgery and sometimes it must be a 20-30 degree increase greater than the level of correction initially provided after surgery.

“The greatest French surgeon of the 19th century,” Guillaume Dupuytren, battled with the problem of reappearance of this disease after surgery. He experimented with a variety of tactics and methods to minimize the return but none were totally successful, just as it is today.

How often does Dupuytren contracture come back after hand surgery?

The general consensus is that after having conservative surgery by needle aponeurotomy, 50% of patients see a return of the same or worse contracture just three years later.  But after having more invasive open hand Dupuytren surgery, 50% of patients will notice a reappearance of the same or worse contracture five years later.  It seems that Dupuytren contracture will tend to come back over time to the same 50% group, but for needle aponeurotomy patients it happens much sooner.

In 2011 the partial fasciectomy is still the most common surgery for Dupuytren contracture.  In this operation the diseased tissue is completely removed and perhaps parts of the palmar aponeurosis might also be excised.  In 1990 McGrouther reported after this kind of surgery anywhere from 2 to 63% of surgery patients will have their Dupuytren tissue changes  reappear, while in 2007 Schwartz reported 44% recurrence after these same surgeries.

MedScape News Today reported in February of 2011 that contracture recurrence rates range from 27% to 80% after palmar fasciectomy (open hand surgery), and are highest  when this technique is used on  the PIP joints of the fingers. This same Medscape commentary reported 65% to 85% contracture problems recur after palmar fasciotomy (needle aponeurotomy).

Little information for laypeople about Dupuytrens returning after hand surgery

Many patients research on the web or elsewhere for information about Dupuytren contracture surgery.  Usually they find little information explaining that the palmar nodes and cords often   reappear a few years, sometimes as soon as one year, after surgery.  While attempting to learn about Dupuytren surgery from a medical website – and recurrence in particular – the reader will often encounter only a single sentence that mentions the word “return” or “recurrence,” with rarely any discussion or statistics to explain the scope or frequency of the problem.  A large medical website promoting palmar fasciectomy or needle aponeurotomy might only comment, “After surgery, a therapy program of massage, wound care, exercises and night time splinting is important to get the best possible result and prevent recurrence.”

While it can be said that such a website does inform people about the possible return of Dupuytren contracture after surgery, the usual mention is so vague and casually presented that a potential surgical patient will not understand the rather high rate at which the nodules and cords come back after being surgically removed.  With limited information being the norm it is difficult for anyone to develop a clear understanding of how often, how quickly, and how problematic is this return of the Dupuytren’s contracture problem after undergoing a surgical release of the constricted fingers.

It is almost as though the popular medical information sources are reluctant to reveal that while Dupuytren surgery can improve the palm and finger contractures for the short term, the results are somewhat temporary and have no beneficial effect on the eventual progression of the disease.

This would explain why over the years the majority of people I encounter through the Dupuytren Contracture Institute are completely surprised and unprepared when they have a reappearance of their hand contractures after surgery; most thought that once they had the  hand operation their problem was solved and would not come back again.  Over and over I learn these people were not told about Dupuytren’s recurrence by their surgeon, or that the idea of needing a second operation was presented as a genuine rarity.  It is a serious problem when patients cannot provide informed consent for their hand surgery because they have not been given adequate information about the post-surgical return of Dupuytren nodules and cords.

Final comment, Dupuytren reappearance after hand surgery

In 1964 Weckesser stated. “In general, the longer the follow-up period [after Dupuytren’s disease surgery], the lower the percentage of good results.”  This means, of course, that surgery for Dupuytren’s contracture does not stop the disease process or prevent its return, but only provides a temporary break from the contractures. This would not be too bad if the time between surgeries was longer or if side effects, or complications from surgery did not make the problem worse for some patients over time.

Better to avoid the first hand surgery if possible.

Dupuytren Surgery and Recurrence of Hand Contracture

Dupuytren surgical treatment temporary relief

After speaking to well over a thousand people about their Dupuytren surgery options, fewer than a handful knew that surgical repair is only a temporary relief of the palm nodules and finger contractures. Only a few knew surgery for Dupuytrens is NOT a one-time and permanent solution.

Recurrence of a second episode of Dupuytren contracture after the first surgery takes approximately five years, sometimes sooner and  sometimes later.  For every example where someone might have a recurrence after as long as ten years, there are many others who have a return in one or two years; five years is a good average.

Here are important ideas to have in mind when you think about having any kind of Dupuytren surgery:

  1. Once you have your first Dupuytren surgery, you will have others because the problem will return.
  2. There is no such thing as cutting the Dupuytrens tissue out and being done with it.  Some surgeon’s refer to cutting out a large and deep mass of tissue as creating a  “firewall of tissue” to keep the problem from returning, but it is only a delay technique.  It will always return; it is just a matter of time.
  3. If you have Dupuytren surgery and your problem recurs in (let’s say) three years, if you have another or second surgery for the first recurrence of the problem your second recurrence will happen in less than three years.   After each Dupuytren surgery the next recurrence happens faster each time.  The return of your hand contracture will be faster after the second surgery, even faster after the third surgery, and even after the fourth surgery, and so on.
  4. After each hand surgery your recovery will be longer and more complicated with greater chance for side effects.  Just like the recurrence problem increasing with each surgery, the amount of numbness, stiffness, pain, scar build up, reduced hand and finger movement and general limitation increases each time you have Dupuytren surgery.
  5. If  your hand has been so scarred, and so much tissue removed by prior surgeries, and pain and limited use of the hand develops, a common solution is to amputate the offending finger(s).

Here is a brief explanation of the different types of Dupuytren surgery and how each rates in terms of recurrence after the first surgery.

  • Regional Fasciectomy: Most common Dupuytren surgery.  The contracted fascia of the palm and involved fingers are surgically removed, requiring general anesthesia or a nerve block.  Requires extended rehabilitation and wound care. Recurrence of Dupuytren contracture – somewhat more frequent than after other types of Dupuytren surgery.
  • Fasciotomy: Less common Dupuytren surgery.  Requires single or multiple incisions (usually in a zig-zag pattern) using widespread dissection over the Dupuytren’s cord, but the diseased tissue is not removed.  Also requires general anesthesia or a nerve block.  Requires extended rehabilitation and wound care. Recurrence is slightly more frequent than a regional fasiectomy.
  • Dermofasciectomy: Less common Dupuytren surgery.  Surgical removal of diseased skin and fascia overlying Dupuytren cords, in which diseased soft tissue of palm is replaced with a skin graft from patient’s forearm.  Requires very long rehabilitation and wound care.  Recurrence is somewhat less frequent than regional fasciectomy.
  • Needle Aponeurotomy (NA): Very popular – and almost faddish – in-office procedure.  While needle aponeurotomy is a minimally invasive Dupuytren surgery in which a needle is inserted and slashed around under the skin of the palm to shred, lacerate and weakened the Dupuytren cords.  After being so weakened, each cord is broken by hyperextending or pulling each finger straight.  Only local anesthesia is needed.  Requires short rehabilitation and minimal wound care.  Recurrence is about average.
  • Collagenase injection: Early in 2010 the US Food and Drug Administration (FDA) approved inject able collagenase extracted from the bacteria Clostridium histolyticum to be used in treatment of Dupuytren contracture.  Collagenase erodes the Dupuytren cords when they are injected with small amounts of this enzyme, breaking the peptide bonds in the cords of collagen.   Recurrence of hand and finger contractures seems to be most frequent with this technique.

None of these surgical procedures has proved to be a way to stop or cure Dupuytren contracture permanently.  It is said that if a patient lives long enough, the finger contractures and palm lumps will return and additional Dupuytren surgery will be needed.

In extreme cases, amputation of fingers may be needed for severe or recurrent disease, or after complications in surgery.

Alternative therapies, such as advocated by Dupuytren Contracture Institute, have received almost no evidence-based research by the large pharmaceutical companies or university medical programs because of their limited profit potential and easy access by laypeople, and so have little support from the medical profession.

♦    Click here to learn more about natural Dupuytren treatment

Dupuytren Release

Dupuytren release is not one type of hand surgery

The term Dupuytren release refers to either of two types of hand surgery: fasciotomy or fasciectomy.  Either of these can be provided to release the thickened and shortened contracture of the hand lump associated with Dupuytren’s disease, resulting in a temporary reduction or release of the tightening and flexion of one or more fingers.

When considering undergoing a Dupuytren release, remember that no release procedure offers a permanent correction; all are a temporary solution because recurrence of Dupuytren contracture will happen sooner or later, usually within three to five years or so.

Dupuytren surgery should be reserved for situations in which the hand contractures keep the involved finger(s) at 30° flexion, or when the individual has a positive tabletop test in which both the palm and fingers  cannot be held flat against a tabletop.

A Dupuytren release involves making one or a series of incisions into the palm to remove the  thick, contracted and inflamed soft tissue (fascia) that surrounds, supports, and separates the tendons and tendon sheaths of the fingers and hand, while preserving the uninvolved skin, arteries, veins and nerves, correcting joint deformities, and maintaining proper flexion and grip strength.

There are five different surgical methods that are termed a Dupuytren release:

  1. Partial or selective fasciectomy – most common Dupuytren release, during which one or more incisions are made across the palm, dependent upon the size, depth and location of the nodules, cords and contractures, as well as history of prior Dupuytren release surgeries and hand trauma, age and occupation. Recurrence  somewhat more frequent than after other types of Dupuytren surgery.
  2. Subcutaneous fasciotomy – Less common Dupuytren surgery.  Single or multiple incisions (usually in a zig-zag pattern) for widespread dissection over the contracted tissue, but diseased tissue is not removed.  Recurrence is slightly more frequent than a regional fasiectomy.
  3. Complete fasciectomy – Rarely indicated because of frequent complications and frequency of recurrence. .
  4. Fasciectomy with skin grafting – Less common Dupuytren surgery.  Surgical removal of diseased skin and fascia overlying Dupuytren cords, in which diseased soft tissue of palm replaced with a skin graft from patient’s forearm.   Recurrence is somewhat less frequent than regional fasciectomy.
  5. Amputation – performed after failed Dupuytren release surgery or after multiple recurrences where no additional surgery is possible.

Dupuytren release not a cure

A Dupuytren release does not cure or eliminate the disease.  When it works out well it will only temporarily modifies the progression of the disease and temporarily improves hand function. When it does not work out well it can result in a worse problem than before the release surgery.  Recurrence is still likely after Dupuytren surgery

Since 2002 the Dupuytren Contracture Institute has maintained that an initially conservative approach to treatment is most prudent and defendable.  If after following a moderate term course of intense non-invasive Alternative Medicine treatment of Dupuytren contracture there is a lack of sufficient response, then more radial invasive measures can always be explored.

The normal and full use of your hands can be taken from you as Dupuytren contracture progresses.  There is an alternate way to do all that you can, as early as you can, to allow your body the best opportunity to naturally reverse this problem.

For ideas and suggestions to organize an effective Alternative Medicine treatment plan, to possibly avoid the need for Dupuytren release surgery, click natural Dupuytren Treatment Plan.

For more information about trying to avoid Dupuytren surgery:

>> Dupuytren Contracture Treatment – FAQs

>> Testimonials from Dupuytren Contracture Institute

>> Dupuytren surgery