SURGERY FOR DUPUYTREN’S DISEASE (DD)
Baron Guillaume Dupuytren (1777-1835), the famous French surgeon for which Dupuytren’s “contracture” was named, may have been the first person to perform surgery on a hand to repair a contracture. Since his original report in 1834, surgeons have been dissecting and disrupting contracture tissues with the aim of restoring hand and finger function. Surgery for DD remains widely used today, in parallel with more recently developed and less invasive treatment alternatives.
In the interests of clarity, we have discussed minimally invasive needle-based procedures such as needle aponeurotomy and collagenase injections in separate sections of this website. Our focus here is on more the invasive surgical procedures that typically require the expertise of a hand surgeon in an operating room of a hospital.
OVERVIEW OF THE SURGICAL PROCEDURES USED TO TREAT DD
There are several different surgical procedures currently used to treat Dupuytren’s disease. In simple terms, most of these procedures can be sub-divided into those that aim to remove the contracted fascial tissues from the hand and/or finger (an “ectomy”) and those that aim to sever the contracted fascial tissues but leave them in place (an “otomy”). The surgical approach originally described by Dr. Dupuytren was the second option, a fasciotomy. Advances in surgical techniques, instrumentation, anesthesia, and hygiene during the 20th century made the removal of contracted tissues from the hand and/or fingers, in the hope of further minimizing disease recurrence, more popular. However, as with all surgeries, the greater the degree of intervention, the greater the risk of unwanted side effects such as wound site infection, nerve damage or prolonged recovery times. Therefore, modern surgical approaches aim to achieve an optimal balance between minimal disruption of hand tissues, maximal recovery of function and minimal disease recurrence.
Based on our discussions with international and Canadian hand surgeons, a partial or “limited” fasciectomy is the most frequently used approach for treating patients undergoing their first surgical intervention for DD. This technique involves the removal of sections (then known as a segmental fasciectomy) or as much of the contracted palmar tissues as possible while leaving any adjacent, visibly unaffected palmar tissues intact. The skin overlying the contracture is incised to gain access to underlying diseased tissues during the surgery, however the skin is not removed and is sutured at the end of the operation.
Fasciotomy involves the dissection and disruption of the contracted palmar tissues without removing them. The development of the needle fasciotomy (aponeurotomy) technique3, which can be performed by a suitably trained physician in a clinic or physician’s office surgery, has largely superseded the need to perform a fasciotomy in an operating room. None of the Canadian or International surgeons we have polled currently perform “surgical” fasciotomies, and most have replaced this approach with needle fasciotomy. Additional information about needle fasciotomy can be found here.
Dermofasciectomy is a more extensive surgical approach where the contracted palmar tissues and the overlying skin are removed (“dermo” means “relating to the skin”). The palmar skin is replaced with a skin graft from another part of the body. Many surgeons chose to perform a dermofasciectomy as a more “aggressive” approach after a partial fasciectomy has failed to prevent disease recurrence.
This approach involves the surgical removal of both the visibly affected (contracted) and visibly unaffected palmar tissues adjacent to the contracted tissues to minimize the likelihood of recurrent contractures. Due to the increased risks of nerve damage, permanent loss of hand function and lack of evidence of benefit for this technique over dermofasciectomy, this aggressive procedure has declined in popularity in recent decades and, to our knowledge, is rarely performed by most hand surgeons in Canada or other countries.
The formation of a dense “nodule” in the palm or finger is widely considered to be the earliest stage of Dupuytren’s disease. Unless they are painful, surgical nodule excision is rarely performed. Since not all nodules progress to the contracture stage of DD, many surgeons consider the risk of exacerbating disease progression in the hand to be greater than the benefit derived from nodule removal. Radiotherapy has recently gained popularity as an alternative treatment for newly formed nodules.
A ray amputation is the surgical removal of a finger along with the bones/tissues of the palm connected to it. Clinically, this is considered a “salvage” procedure, where use the affected hand is salvaged by complete removal of the contracture-prone palmar/digital unit. A surgeon will typically resort to a ray amputation only after all other viable treatment options have been unsuccessful. A ray amputation does not prevent the formation of nodules and/or contractures in the remaining fingers and palm.
During the recovery period after surgery on your hand for DD, your surgeon may recommend the use of a splint, typically for 6-12 weeks, to protect the surgical site and maintain finger extension. Post-surgical splinting is a controversial subject, with some surgeons maintaining that post-surgical splinting is beneficial to recovery while others point to the lack of clinical evidence supporting this procedure. Any decisions regarding post-surgical splinting should be made in consultation with your surgeon.
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