Techniques of hand surgery

While the above comments refer to hand surgery of Dupuytren's disease in general, actually a wide variety of techniques is being applied. We are giving an overview but there are many variants. Dupuytren himself in the 19th Century used to not remove the cord but to just cut it and thus regain flexibility of the finger, similar to today's less invasive NA technique. Improvements in surgical techniques, anesthesia, and hygiene in the 20th Century made it possible to safely remove larger amounts of tissue in an attempt to reduce recurrence of the disease. Those attempts to remove all of the diseased tissue, unfortunately, still showed some recurrence, required significant longer recovery, and exhibited more severe side effects. Therefore later several techniques of reduced surgery were proposed. The goals were faster recovery, less side effects, without increasing the rate of recurrence.

The recurrence rates given below are actually coarse estimates for several reasons. Though many publications provide numbers on recurrence rates, the definition of recurrence varies. Recurrence might mean for example that the finger had to be treated again or that the condition just got worse after treatment or that the condition got worse resulting in a higher Tubiana stage of the disease. All those definitions are actually being used. Obviously also the analyzed period of time is important ("In general, the longer the follow-up period, the lower the percentage of good results" Weckesser_full article). Often also the provided numbers are based on a relatively weak statistical set of data. Further difficulties arise fom the influence of the surgeon's skill, the patient's condition ("Patients with Dupuytren contracture vary greatly in their propensity to reform contracture" - see Weckesser), the strong dependence on the affected finger and joint, and the - rarely assessed - extension to other areas potentially triggered by surgery.

 

Overview of surgical techniques

Total fasciectomy

Generously removes all of the diseased tissue and often also the aponeurosis which is sometimes believed to be the source of the disease. Due to hgher risk of functional loss of the hand this techniques has become less popular in the last few decades. Recurrence rate estimated 20 - 40 percent after five years.

Partial fasciectomy

Currently probably the most frequently applied technique. The diseased tissue is completely removed and sometimes also parts of the aponeurosis. The range of reported recurrence varies widely: "In an exhaustive review of the literature, McGrouther (1990) found percentages of recurrence oscillating between 2 and 63%" (see Moermans, chapter 14.5). On average the recurrence rate might be 40 - 50 percent.

Nodule fasciectomy

Removes only the nodule (sometimes also the cord) and leaves in place the aponeurosis which is not considered as critical to disease development. Depending on the disease's stage cords will be cut but not fully excised (subcutaneous fasciotomy). "If it be true that the nodule is the essential lesion, and my studies indicate that it is, it is not necessary to do a radical excison of all the palmar fascia and associated fibrous cords" (J. Vernon Luck "Dupuytren's Contracture - A New Concept of the Pathogenesis Correlated with Surgical Management" Journal of Bone and Joint Surgery (1959) p 635-664 full_article_luck). The recurrence rate is probably similar to partial fasciectomy.

Segmental aponeurectomy

Only segments of the cord are removed allowing smaller surgical intervention and faster recovery. "The basic postulate of segmental aponeurectomy is that, if we can create a permanent discontinuity in the retracted aponeurotic band without wide dissection of the fascia itself, then the retracted band from which tension has been eliminated will disappear or at least cease to act as a contracture." (Moermans). The recurrence rate, according to Moermans, is about 35 percent (but Moermans' definition of recurrence is very pessimistic, other researchers would have probably reported a lower recurrence) and depends strongly on the affected finger and the affected joint, an effect that is often ignored in other publications.

Dermofasciectomy

Dermofasciectomy removes all of the diseased fascia plus a generous amount of the overlying skin which is replaced by skin from other parts of the body. This technique is one of the larger surgeries but is reported to have a very low recurrence rate of about 10 percent (not for cords but for a more diffuse variant of Dupuytren's disease, see e.g. J. R. Amstrong et al. "Dermofasciectomy in the management of Dupuytren’s disease" J Bone Joint Surg [Br] 82-B (2000) p 90-94 full_article). Further readings http://www.lynndketchum.com/surgeries.htm , Moermans Chapter 15, list of recent articles. The benefit of dermofasciectomy might be related to observations reported by Pasquali-Ronchetti et al. "A clinical, ultrastructural and immunochemical study of Dupuytren's disease" J Hand Surg [Br] 18 (1993) p 262 -269 abstract. The authors observed cells similar to the obviously diseased nodule areas also in other, seemingly not affected areas of the skin.

 

Treatment after hand surgery, night splint

Immediately after surgery the hand is bandaged. After a few days careful exercises will get hand and fingers flexible again. This kind of physio training should be supported by an expert. Varous techniques are being used to excercise the hand, we refer e.g. to Benson et al. "Dupuytren's contracture" J Am Acad Orthop Surg. 6 (1998) p 24-35. "The mainstay of postoperative hand therapy is early active-flexion range-of-motion exercises to restore grip strength. A nighttime extension splint is often used for several months postoperatively to maintain the correction achieved in the operating room."

To maintain flexibility of the hand during the day and to avoid damage at night, splints are usually worn at night. Below is a comfortable night splint that can also be used after needle aponeurotomy. The period of wearing a night splint varies strongly, with some patients wearing night splints up to 6 months.

Comfortable night splint supporting the three fingers most frequently affected by Dupuytren's contracture.

( Picture provided by A. Meinel, Dupuytren Ambulanz )

Page last modified: 03/26/2008