Dupuytren’s Contracture Surgery

Dupuytren’s disease refers to a disorder of the palmar aponeurosis of the hand (tendinous structures of the palm). This disorder is named after its first describer, Baron Guillaume Dupuytren (1832, Paris). Dupuytren’s contracture is manifested by a nodular, cord-like hardening of the palmar aponeurosis (tendon plate in the palm, which is the continuation of the tendon of the long palmar muscle) with an increase in coarse connective tissue, which can lead to a flexion contracture of the finger joints (due to the pull of the hardened connective tissue, the fingers are forced to bend and can only be stretched again with difficulty or not at all). Typically, the small and ring fingers are affected (rarely all long fingers). Flexion contractures are found almost exclusively at the finger base and middle joints due to the inability to extend the fingers. There is no pain in the process. The cause of the disease is not known.Dupuytren’s disease is classified as benign fibromatosis (benign growth of connective tissue). A similar clinical picture on the foot is called Ledderhose’s disease. Some points are discussed as predisposing factors:

  • Genetic disposition – familial accumulation.
  • Ethnic context – African and Asian peoples are rarely affected.
  • Gender – men are more often affected than women
  • Age – accumulation at an older age (50-70 years).
  • Connection with other diseases – alcohol abuse, diabetes mellitus (diabetes), pathological liver parenchyma (damaged liver tissue, for example, in cirrhosis), chronic trauma (frequent injuries to the palm).

Consumption of citrus fruits and unsaturated fatty acids is considered a protective factor! Dupuytren’s disease progresses episodically and is divided into different stages, according to this classification is the selection of appropriate therapy:

Classification according to Tubiana:

  • Stage 0 – strands and nodes without joint contracture.
  • Stage 1 – contractures from 0-45°.
  • Stage 2 – contractures from 45-90 °
  • Stage 3 – contractures from 90-135 °
  • Stage 4 – contractures over 135 °

Classification according to Iselin:

  • Stage 1 – nodules in the palm
  • Stage 2 – flexion contracture in the base joint.
  • Stage 3 – flexion contracture in the base joint and middle joint.
  • Stage 4 – in addition to stage 3, a hyperextension in the terminal joint.

Diagnosis of Dupuytren’s contracture is usually made clinically by palpation (palpation) of the hardened tendon cords. In the early stage, any nodular structures can not yet be clearly assigned. A classic X-ray of the hand allows the detection of possible arthritic damage that may result from the malposition of the hand and fingers. The therapy of Dupuytren’s disease can be divided into conservative and surgical measures. Conservative therapy consists mainly of X-ray irradiation of the contractures, ultrasound treatments, laser treatment, local injections of cortisone, steroids and enzymes such as trypsin or collagenases, as well as the administration of vitamin E. Surgical therapy appears to be far more effective. Depending on the stage and location of the contractures, various surgical interventions allow for reversal of disability and relief of pain that may result from irritation of the digital nerves (finger nerves).

Contraindications

Before surgery

Before surgery, a detailed medical history should be taken and the patient should be informed about possible complications. Radiographic examination of the hand, in addition to thorough clinical examination, ensures selection of the appropriate surgical method. Platelet aggregation inhibitors (blood thinning medications) should be discontinued approximately 5 days prior to surgery. To support wound healing, it is recommended that the patient discontinue nicotine use.

Surgical procedures

Surgical therapy is already indicated in stage 2 because early intervention has a positive effect on the outcome. The goal of the surgical procedure is to improve mobility and to eliminate the flexion contracture so that the patient can extend his or her finger again. Depending on the location of the contracture, a different surgical technique is suitable; the following surgical techniques are available:

  • Fasciotomy (strand transection) – in this simple procedure, Dupuytren’s strand is transected transcutaneously (through the skin). Since this procedure involves a high risk of nerve injury and has a high recurrence rate (80%), the method is rarely used.
  • Limited strand excision – transcutaneous removal of single nodes.
  • Partial fasciectomy – this surgical procedure removes all visibly altered fibrous cords as well as portions of healthy connective tissue. If the aponeurosis (tendon plate) of the palm is affected, access to the diseased tissue is made through an incision that passes in the palmar flexor crease. In affected fingers, a longitudinal incision is made in the median line (midline) of the finger. However, a Z-plasty should be used here when closing the surgical wound to avoid renewed flexion contractures (A Z-plasty is the Z-shaped placement of the surgical suture; since scar tissue is coarse and not very elastic, a longitudinal suture would again fix the finger in the flexed position. With a Z-plasty, the traction through the scar runs in a zig-zag pattern so that the finger can be stretched well). After making the incision, the diseased tissue is carefully dissected free, sparing the nerves and vessels, and all macroscopically visible (to the naked eye) Dupuytren’s cords as well as parts of the healthy tissue are removed. In addition, a wound drainage is placed.
  • Partial aponeurectomy – surgical removal of parts of the aponeurosis tissue; the tissue altered by the disease is completely removed, unaffected ligamentous and aponeurosis structures are left [primary surgical procedure].
  • Sharp aponeurotomy – surgical transection of the aponeurosis (tendon plate), i.e. transection of the nodular-fibrous strand via a small skin incision [procedure of secondary importance].
  • Total aponeurectomy – surgical transection of the aponeurosis (tendon plate) in its entirety [procedure of minor importance].
  • Radical fasciectomy – in this variant, all parts of the tight connective tissue (diseased and healthy), which are usually diseased, are removed. Since the complication rate is very high and the recurrence rate is unchanged, partial fasciectomy is more commonly used.
  • Dermatofasciectomy – complete surgical removal of a complex of skin as well as the underlying Dupuytren’s contracture cord using a full-thickness skin graft to cover the soft tissue defect.
  • Local fasciectomy – Exclusive surgical removal of diseased tissue, usually performed on the fingers. However, here the spread of Dupuytren’s disease is likely in another location.

After surgery

To prevent a hematoma (bruise) on the palmar side (hollow hand), a pressure pad is incorporated into the dressing. A finger forearm plaster splint is applied to the extensor side of the hand. Therapeutic mobilization of the operated area is already advisable on the first postoperative day. The plaster splint can be removed for this purpose. The goal is to regain normal functionality, as is necessary for everyday life and work. Continuous control of blood flow and sensitivity of the surgical area is obligatory.

Possible complications

  • Vascular and nerve damage – Long-lasting skin aesthesia (numbness of the skin).
  • Wound healing disorders
  • Postoperative – hematoma, edema (swelling).
  • Recurrences (recurrence of the disease).