Dupuytren's disease, also called Dupuytren’s contracture, is a progressive condition that causes the fingers to bend toward the palm at the first or second joint. Unusual cords and knots of tissue form in the fascia that holds the palm skin in place. The unusual tissue reduces the patient’s ability to straighten fingers and use their hand normally.
The medical term for this bending is “flexion contracture;” flexion means bending and contracture means thickening or shortening. The fingers most often affected are the small and ring fingers. The thumb is affected less often.
Surgery – removal of the abnormal fascia tissue – is the mainstay of treatment for Dupuytren’s disease. Surgery is indicated when the patient and surgeon agree that the condition causes significant problems for the patient and that surgery will likely improve the condition. Sometimes surgery targets only the most affected fingers. If several fingers are severely affected, then all might require surgery.
Partial palmar fasciectomy is the most widely accepted surgery for Dupuytren’s disease. The surgeon removes the abnormal Dupuytren's tissue from the palm and affected fingers. This can involve a number of incisions, depending on the surgeon's preferred approach. At the end of the operation, all of the incisions might be sutured closed or some might be left open to allow drainage.
Total palmar fasciectomy is the removal of all fascia, no matter whether it is involved in Dupuytren’s disease.
Palmar fasciotomy is the surgical procedure that cuts the Dupuytren's cords in the palm. A recurrence of Dupuytren’s disease is higher with this surgical treatment, though it’s often useful for patients who have other debilitating conditions.
Before the operation, the surgeon and the patient decide together which fingers will be operated on and whether to use a general anesthetic, putting the patient to sleep, or a regional/local, in which the patient remains awake. The outpatient surgery means that the patient usually goes home the day of the surgery. Length of the surgery is related to the number of fingers involved and the contractures’ severity. For this reason surgery can take one to several hours.
The arm and hand are washed with an antimicrobial solution to decrease the risk of infection. During surgery, a tourniquet (similar to a blood-pressure cuff) is placed around the arm above the elbow. Sterile drapes are placed around the hand and arm, and the tourniquet is inflated to minimize bleeding during the operation.
The surgeon makes incisions in the palm and the affected fingers. Several incisions can be used (Fig. 1
The arteries and nerves going to the fingers are identified and protected to prevent injury. Abnormal fascia is removed, allowing improved motion of the affected finger. Sometimes it is necessary to further resect nearby tissue structures to achieve improved motion. The surgeon may make Z-shaped incisions over areas of skin tightness to allow skin to lengthen, further improving finger motion. In severe cases, palm skin also is removed and replaced with grafts – thin pieces of skin taken from another area of the body.
The tourniquet is deflated and bleeding controlled. The incisions are closed (though some may be left open to allow drainage) and a dressing and splint are applied.
While surgery can restore significant function, it is not always possible to achieve full correction. Success depends on which joints are affected, the severity of the deformity and how long the deformity has been present.
While surgery remains the gold standard of treatment, clinical trials are evaluating the effectiveness of collagenase injections. Collagenase is an enzyme that breaks down collagen, the molecule that makes up the cords of Dupuytren's tissue.
Initial studies have suggested that most patients in the trials experience improved finger motion when treated with collagenase instead of surgery. The results of the current trials will shed more light on this new technique, but only time will tell the potential for recurrence of Dupuytren’s after collagenase injections.
Other non-surgical treatments have been reported:
- pre-operative splinting
- steroids applied either on the skin or injected
- dimethyl sulfoxide (DMSO), a type of solvent
- colchicinesa: a drug often used to prevent or treat gout
- gamma-interferon, a drug used to help fight certain serious infections.
None of these has shown significant benefit or established itself as a treatment option for Dupuytren's disease.
MedicationsBefore leaving the hospital, patients will receive a prescription for narcotic medication to help manage pain. Narcotics usually are required only for the first few postoperative days; thereafter, doctors prefer that patients take over-the-counter medications such as acetaminophen or ibuprofen. It is important for patients to inform their doctor if they have an allergy to narcotic medications.
Narcotic medications have several side effects. These include but are not limited to rashes, drowsiness, nausea and vomiting, itchiness, constipation and serious allergic reactions. Patients cannot drive or operate machinery while taking a narcotic.
Once Dupuytren's disease is diagnosed, it’s usually observed for a period because it does not usually significantly interfere with hand function.
Surgery does not cure the disease, and the contractures recur in about half the patients following surgery. Therefore, surgery is often avoided unless the condition causes a significant loss of hand function or persistent discomfort.
Indications for surgery:
- finger(s) contracted more than 30 degrees at the first knuckle, closest to the wrist (metacarpal phalangeal joint)
- progressive contracture at the second knuckle (proximal interphalangeal joint)
- persistent pain
These guidelines are not rigidly followed. Generally, surgery is warranted when the patient and surgeon think that the condition is causing significant problems for the patient that will likely be improved by surgery.
EffectivenessMost patients experience improved hand function after surgery for Dupuytren's disease – specifically, an improved ability to straighten or extend the fingers and decreased contracture.
The degree of benefit is difficult to predict before surgery, but it is related to the severity of the contracture and the joint(s) involved. In general, contractures of the second finger joint (nearer the fingertip) are more difficult to correct, as are longstanding contractures. Improvements usually last several years. About half of the patients have recurring contractures five to 10 years after surgery.
Potential complications exist with any operation. In surgery for Dupuytren’s disease, these include:
- hematoma (a collection of blood under the skin)
- skin necrosis (death due to poor blood supply)
- recurrence of the disease
- finger stiffness requiring physical therapy
- injury to nerves and blood vessels
If complications such as nerve or vessel injury occur during surgery and are recognized, they are repaired at that time. It is uncommon for a nerve or vessel to be cut, though this complication can occur.
Nerve injury can cause finger numbness, which is usually temporary but might be permanent. Straightening a finger during surgery can over-stretch and damage vessels that had contracted with disease. This can reduce blood flow to the finger, but usually improves over several minutes of relaxing the finger and applying warm sponges. When vessels are damaged, the worst-case scenario is loss of the finger, though this is rare.
Infections that occur after surgery are treated with antibiotics, taken orally or intravenously, depending on the infection’s severity. Occasionally, an infection requires a return to the operating room for drainage. If skin necrosis occurs, the medical team’s first course of action is to observe the situation, followed by later removal of the dead tissue. Often the wound will heal on its own with dressing changes, but a skin graft might be required to close the wound.
Hematoma (a collection of blood under the skin) is managed with observation if the hematoma is small enough for the body to reabsorb in time. Larger hematomas require drainage to prevent skin necrosis and infection.
Physical therapy and splinting can help reduce the likelihood of recurrence. Many patients, despite those efforts, do experience some recurrence of Dupuytren’s.
Risks of not having palmar fasiectomy
It’s preferable to postpone surgery if Dupuytren’s disease does not significantly interfere with the patient’s daily activities. The condition may remain stable for long periods, in which case no surgery is needed. In other instances, the disease progresses rapidly. It is difficult to predict how quickly the disease will progress in each patient.
Postponing surgery is not dangerous to the patient's general health. In fact, surgery should be avoided unless the contractures significantly impair the patient's ability to perform daily activities. Occasionally, surgery is performed to relieve severe pain from Dupuytren's nodules or to facilitate personal hygiene in patients with severe contractures.