Fasciectomy - Surgery for Dupuytrens

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Published: Tuesday, 29 May 2018 20:49

Written by Dr Stuart Myers

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Fasciectomy - Surgery for Dupuytrens

- Fasciectomy means that the  Dupuytrens cords and nodules are surgically removed to allow partial or complete correction of deformity in the fingers.

This involves extensive surgical incisions and dissection.

-    It gives the best chance of correction of deformity but involves extensive dissection and greatest risk of scar tissue formation compared with other treatments for Dupuytrens.  Some people liken it to a “shark attack” on the hand.

After the Dupuytrens tissue is removed.

Indications:
- Very thick cords or where multiple fingers are involved. The significance is that  it may take many Xiaflex injections to achieve a cord rupture which would be prohibitively expensive.

- Where Xiaflex is contra-indicated 
- Recurrent Dupuytren’s disease after previous surgery
- Disease involving PIP & DIP joints ( Relative contraindication) - The further down the finger the greater the risk of injury to nerves and vessels with needle insertion.

Procedure
 
It is performed as a Day only or Overnight  procedure in the operating theatre under a combination of local anaesthetic block and general anaesthetic.

When  the finger has  been flexed for some time  due to contraction of the Dupuytrens cords there is a secondary consequence for other structures in the finger:

 - The skin on the front ( or volar side) of the finger contracts- when the deformity is corrected there is not enough skin to allow the finger to straighten. The solution is either:
                      - Local skin flaps  Z plasties    or      V-Y plasties.
                      - Skin grafts
 - The ligaments may contract – especially at the PIP joint level and may require separate release. The risk is that this can cause increased bleeding around the joint with subsequent scar tissue and stiffness. It is only undertaken if the residual deformity after removing the Dupuytrens tissue is greater than 30*.
 - Nerves and arteries may also contract. If this occurs it may result in lack of blood supply to the finger when it is stretched out and may limit the correction possible. It may also potentially result in reduced sensation in the finger after correction.

-    Drains are  often  inserted in wound at the end of the procedure to remove any delayed bleeding from the wound
-    Plaster then a splint at night  then move fingers during daytime
-    Post op Hand Therapy with night splints for 6 – 12 weeks
-    Prolonged recovery 6 – 12 months

Skin shortage after deformity correction
If the finger has been bent for a long time the skin contracts on the front of the finger.
The relative skin shortage once the finger deformity has been corrected can be overcome with either local skin flaps ( Z plasties or V-Y plasties ) or for larger defects with skin grafting.

Sometimes the horizontal components of the wounds are left open and heal from underneath.

                   

The advantage of skin grafting is that the Dupuytren’s tissue does NOT re-form under a skin graft and so this tissue can act as a “fire break” to the disease.

Grafting does slow the rehabilitation process and it is absolutely critical to keep the hand elevated for 2 weeks after the surgery to allow the skin graft to “take”. An ellipse of skin is removed from the inner aspect of the arm. Because the skin is lax here it can be easily closed leaving a straight line scar ( a buried suture is used to close the wound).
 

More information on Skin grafting for Dupuytrens

Benefits of Fasciectomy:

- Best correction of deformity
- Longest duration of disease free time after intervention
-  Removes the diseased tissue and delays recurrence of the disease.

Disadvantages of Fasciectomy:

- Larger operation with slower recovery and greater incidence of complications including : -
     - Infection
    - Stiffness
    - Regional pain syndrome

- Dupuytrens disease will eventually recur if one lives long enough. It is a progressive disease. The rate of recurrence  may be significantly reduced by adding skin grafts. 

- Revision  surgery is  more difficult with a greater incidence of complications.

Complications of Surgery:
Are common and overall effect 10% patients.

Factors that increase the complication rate include: - Greater initial deformity / severe disease - Recurrent disease

1. Nerve damage:
Sometimes the nerves are surrounded by the Dupuytren’s tissue and they must be very carefully dissected from the abnormal tissue. Occasionally there may be a loss of feeling in the fingers as a result of surgery so close to the nerve. This is usually temporary. Some skin flaps ( Z plasties) have permanent change in sensation.

2. Incomplete correction:
The more bent the finger before treatment, the more difficult it will be to get the finger completely straight with treatment. This is especially true for the middle (P.I.P.) joint of the finger. At the completion of treatment it is far more important to be able to make a full fist than to get your finger fully straight. Sometimes a small amount of residual deformity is accepted at surgery rather than risking more scarring in an attempt to get the finger completely straight. If the contracture has been present for a long period of time, then the ligaments in the joint may need to be released to get the finger straight. Sometimes metal pins may be used to hold the joint straight for a short period of time after the operation.

3. Healing problems:
In order to remove as much tissue as possible the skin must be left somewhat thin. Occasionally a flap of skin may die. If this happens, then the wound will heel gradually with dressings or a skin graft might be necessary. It may not be possible to straighten out the finger all the way because the blood vessels have shortened and when the finger is straightened out completely, circulation to the fingertip is cut off. In this case, the finger must be left slightly bent and additional straightening obtained gradually after surgery, with physiotherapy. Failure of a skin graft to “take” is very rare.
It is very common for the wound to look good at 10 days then go purple at 3 weeks. This is part of normal wound healing. The scar usually fades to white after 12 months.

4. Infection: ( Rare)

5. Stiffness:
After surgery, hand therapy is necessary to regain the flexibility of the fingers. A night splint is worn for 6 weeks. In approximately 10% of patients the hand will become stiff and swollen and it may take many months to regain finger movement.

6. Progression / Recurrence of Dupuytren’s disease:
Although the surgical removal of diseased palmar fascia tissue for Dupuytren's contracture is usually successful in improving the ability to straighten the fingers, in some people the condition may reoccur in the same area at a later time.

For Percutaneous fasciotomy 50% in 3 years.
For Open Fasciectomy 50% in 5 years.
This is especially true for people who have had a rapid progression of the condition initially.
If the condition reoccurs, it may be possible to remove it again by a similar operation, or it may be necessary to remove the overlying skin as well and replace it with grafted skin. Occasionally surgery in one part of the hand can trigger the disease in another part of the hand.

7. Complex Regional Pain Syndrome
Potentially  the worst complication of any hand surgery or hand injury. More Information.

For these reasons Dr Myers only recommends surgery when he feels that the benefits of surgery outweigh the risks.