Excision of Dupuytren’s disease can be a fine and complex operation. The disease consists of thickened fibrous tissue in the palm of the hand. The strips of fibrous tissue contract to form tight cords. If these span across the joints, they can cause contractions of the joints and prevent extension.
The degree of severity is quite variable. The little and ring fingers are more commonly affected, however it can affect any digit. The surgical approach to Dupuyren’s disease involves, most commonly, an excision of the diseased tissue.
One of the difficulties with Dupuytren’s excision is that the diseased tissue often wraps around the digital nerves running to the fingers.
A large portion of the operation is spent identifying the digital nerves and dissecting these free from the intertwining diseased tissue. This has to be carried out slowly and methodically.
The procedure is best performed under a general anaesthetic. A tourniquet is applied to the arm. This prevents blood flow in and out of the arm and ensures that the operative zone is dry. This makes it easier to identify and visualise the deeper structures in the hand.
An incision is made over the top of the Dupuytren’s cord, extending for the full length of the diseased tissue. The skin flaps are very gently elevated. Often the diseased tissue is very close to the surface and the skin flaps may be quite thin.
Once the digital nerves have been identified and protected, the diseased tissue is gradually removed. In some cases, this may necessitate extending the incision along the length of the finger to ensure that all of the joints are fully released.
In most cases, the joints will free up and can be stretched into extension. In some cases however where the fingers have been very contracted for a prolonged period, a full release of the joints may be required. This may involve freeing up some of the supporting tissues around the joint that may have become contracted over time.
Once the diseased tissue has been excised and the joints freed, the next stage is skin closure. If the fingers have been flexed for a prolonged time, the skin may be tight and difficult to close. In most cases, small rotational flaps of skin are elevated and rotated to allow the skin closure.
This results in a zigzag appearance to the scar but allows the use of neighbouring skin tissue to assist in the closure of the wounds. The zigzag scarring also reduces the risk of further contraction occurring as the scar matures.
Local anaesthetic is injected to provide good pain relief in the early post-operative phase. The wounds are closed with either absorbable sutures or on some occasions nylon sutures.
The hand is placed in a plaster of Paris splint to provide support. Most patients remain in hospital overnight for elevation and pain relief if needed.
The wounds are kept clean and dry for the first two weeks. At that stage, the dressings are taken down and if necessary, sutures are removed. It is still very common for the hand to feel quite tender and there may be some stiffness with finger movement.
In some cases, hand therapy may be required to work on regaining the range of movement. The scars continue to mature over the next few weeks. Patients who are involved with desk based duties, such as typing or administrative work, may be able to return to work within the first 2-4 weeks after surgery.
Patients who rely on their hands for heavier activities will still be restricted for at least the first 4-6 weeks after surgery.
All operations carry an element of risk. There is potential for nausea and vomiting in relation to the anaesthetic and some patients may be sensitive to certain types of analgesia. As with all open approaches, there is the potential for skin bacteria to cause wound infections.
As mentioned, a lot of time is spent carefully dissecting the digital nerves free from diseased tissue. This may result in some bruising or swelling around the digital nerves which can result in temporary altered quality of sensation. This usually resolves over a few weeks but on occasions, patients may have some persisting decreased quality of sensation.
Occasionally some of the skin flaps may have difficulty healing, especially if the flaps are very thin or the skin is of poor quality. In patients who have had significant contractions of the fingers before they get to surgery, the joints may still have some residual stiffness and there is a risk of further scar formation causing tightness.
Dupuytren’s disease always carries a risk of recurrence. This is more pronounced in patients who present at a younger age and in those with more rapidly progressive disease. There is always the possibility of the disease recurring over time.