Mr.JamesHenderson
MA,MB,BChir,MRCS,MD,FHEA,
EurDipHandSurg,FRCS(Plast)
ConsultantPlastic,Reconstructive&HandSurgeon
HonorarySeniorLecturer,UniversityofBristol
PersonalAssistant
SarahGamlin
[email protected]
07913610304
Dupuytren’sContracture
NamedafterBaronGuillameDupuytren,whotreatedasoldierinNapoleon’sarmyfor
acontracture.Dupuytren’sisagraduallyprogressingconditionwherecordsunderthe
skinslowlypullthefingersintoacurledupposition.Thickeningonthebackofthe
fingers(‘Garrodspads’)mayoccur.Theconditionisnotgenerallypainful,andcarries
nodirectrisktohealth.
Thecauseoftheconditionisunknown,butitismainlygeneticandrunsinfamilies.
Smokingandalcohol,manualworkandcertainmedicationshavebeensuggestedto
contribute,buttheirroleisminorifanything.
Theringandlittlefingersarethemostcommonlyaffected,butitcanoccuranywhere
inthehand,andcanbeassociatedwithsimilarcontractureselsewhereinthebody.
Thecontracturescanbeverydisabling,andneverimprovespontaneously.Splinting
or stretching are not of benefit. Even after treatment, the process that causes the
contracturescontinues,andmanypatientsneedfurthertreatment,althoughwehope
thatthiswillnotbeformanyyears,ifatall.
Theproblemoccursinthefasciaofthepalmofthehand.Thefasciaisastrongnetwork
offibresthatanchorstheskinofthepalmtothedeepstructures,sothatitdoesn’t
sliporslidewhenwewanttogripanobject.Thiscanbeseenquiteeasilybycomparing
therelativelyimmobileskinofthepalmwiththeverymobileskinonthebackofthe
hand.Fasciaismadeoffibresoftheproteincollagen.
Treatment
ThetreatmentofDupuytren’scontracturewilldependonitsseverityandthewishes
ofthepatient.Allthetreatmenttechniquesaimtodividetheaffectedfasciainthe
palm or fingers, and for a longer lasting solution, the fascia is removed, to try to
preventrecurrence.Icanofferawiderangeoftreatmentoptions,andwilldiscuss
thesewithyou.
NeedleFasciotomy
Somemildcasescanbetreatedbysimplydividingthecordinthepalmwiththesharp
pointofaneedle.Thisminimisesthetraumatothehand,andforsomecontractures
canbeveryeffective.Ofcourse,becausethereisnoattempttoremovetheaffected
fascia, the disease will eventually recur. This treatment may be appropriate for
patients with a very mild condition, or a single cord in the palm, as well as those
unwillingorunabletoundergoalargerprocedure.
LimitedFasciectomy
An‘-ectomy’means‘takingsomethingout’ratherthanjustdividingit(‘-otomy’).A
limitedfasciectomycanbeperformedunderlocalanaesthetic,andinvolvesasmall
operation to remove a section of the diseased fascia. This is done with the aim of
preventingordelayingtherecurrenceofthedisease.
Fasciectomy
For more extensive Dupuytren’s disease, an attempt is made to remove all of the
affectedtissue.Thistypicallyinvolvesacutfromthepalmupalongthefinger(s).The
nerves,arteriesandtendonsofthefingerareidentifiedandcarefullyprotected,and
alltheaffectedtissueisremoved.Theaimofthisoperation,inadditiontoallowing
thefingertostraighten,istopreventrecurrenceofthecontracture.
JointRelease
Duetoanunfortunatequirkofnature,themiddleknuckleofthefingerdevelopsa
problemifitisheldcurledupfortoolong,andthisisacommonproblemwithsevere
Dupuytren’s contractures. The ligaments that stabilise the joint become shortened
afteraperiod,andthejointcannotbeextendedevenifalltheaffectedDupuytren’s
disease tissue is removed. The solution to this problem is to carefully release the
ligaments of the joint, elevating them from the bone whilst protecting the nerves,
arteriesandtendonsthatoverliethem.Thejointcanthenbestraightened.
This procedure is relatively straightforward, although in severe cases the tendons,
nerves and arteries have also become shortened, and this can limit the amount of
straighteningpossibleinthefinger.
SkinGraft
Some patients find that the Dupuytren’s disease involves the skin of their palm or
finger-nodules,andpitscandevelop.Itmaynotbepossibletosavetheskinandstill
treat the disease adequately. In this situation, the skin involved can be carefully
removedandreplacedwithaskingraft.Iusuallytaketheskinfromhigheruponthe
samearmdependingontheamountneededandpatientpreference.
Collagenase(Xiapex®)
Inthepastcoupleofyears,Xiapex®(akaXiaflex®)hasbecomeatreatmentoption.
Thisisanenzymecalledcollagenase,whichisisolatedfrombacteriainculture.The
enzymebreaksdownthecollagenintheDupuytren’scords,whichcanthenbebroken
by manipulating the finger. This means that Dupuytren’s disease can be treated
withoutsurgery.Ihavefoundthistobeaveryeffectivetreatment,butitcannotsolve
everyproblem,andIstillrecommendsurgeryformanypatients.
Collagenasetreatmentstillleadstoalotofbruisingandswellinginthehand,andthe
skin often tears during manipulation, because it is too tight to allow the finger to
straightenotherwise.Thisusuallyhealsupextremelywellbutneedstobeexpected.
Scars
Idesignmyscarstolooklikezigzagsbecauseallscarsshortenastheyheal.Thescaris
plannedsothatasitshortensitwon’tmakethefingerbendagain.Intimethescars
healtobealmostinvisibleformostpatients.Skingraftsareusuallyrectangularoroval
inshape,againplannedtolimitdiseaserecurrenceandpreventcontractures.Iusually
usedissolvingstitches,soyoudon’thavetoworryabouthavingthemremoved.
Physiotherapy
Aftersurgeryorcollagenasetreatment,Iregardexpertphysiotherapyasanessential
partofthetreatment,andIworkwithateamofspecialisthandphysiotherapistswho
willprovidethenecessarysplintingandexercisesthatwillenableyoutorecoveras
quicklyaspossible,whilstpreventingscarproblemsorstiffness.Thephysiotherapy
canbehardwork,andyouwillneedtoattendregularly.Thisenablesustoroutinely
obtainexcellentresultsafterDupuytren’ssurgery.
Timeoffworkandactivities
Itgenerallytakes2-4weeksforpatientstoreturntodrivingandnon-manualwork.
Thewoundsareusuallyhealedintwoweeks.Patientswithskingraftsmaytakealittle
longertogetbacktowork.
Risksofsurgery
Coldintolerance–Afteranyhandsurgeryitisnormalforpatientstoreportthattheir
handismoresensitivetothecold.Thisresolvesgraduallyoverseveralwinters,but
canbeannoying.
Nerveinjury–Itisextremelyunlikelythatyouwillsufferapermanentnerveinjuryif
Idoyoursurgeryforyou,butthereisasmallriskofanervetothefingerbeingdivided.
Thiscanleadtonumbnessinthefinger,andapainfulneuroma(nervescar)canresult.
Thenervesdohavetobecarefullyfollowedandprotectedduringthesurgery,andthis
canleadtotemporarynumbnessaftersurgery.Theriskislessthan1/300.
Arteryinjury–Therearetwoarteriestoeachfinger,anditisveryunlikelythatthey
would be injured. In operations for recurrent Dupuytren’s disease, if one of the
arterieswasdamagedbythesurgeonwhodidthefirstoperation,thenanydamage
totheremainingarterycouldputtheentirefingeratrisk.
Failuretofullycorrectthepositionofthefinger–Althoughitisusuallypossibleto
fullycorrectthepositionofafinger,sometimesitisbettertoacceptasmalldegreeof
deformity. Releasing tightened ligaments can lead to scarring that may make the
fingerstiff.Thismayrequireintensivephysiotherapyafterwards,andsplintscanbe
requiredatnightforuptoayear,
Recurrence–Itisnotpossibletocuretheprocessthatcausesthecontracture.Surgery
orcollagenasecanremoveordividethediseasedtissue,andcanstraightenfingers,
but inevitably the process will recur. It is said that half of all patients will require
furthertreatmentwithinfiveyears.Icantakeanapproachwithmysurgerytotryto
reducerecurrencebyremovingasmuchinvolvedtissueaspossible.
Woundbreakdown–ThewoundsthatImakeonyourhandarespecificallydesigned
tohealaswellaspossibleandtoavoidscarproblemsorcontractures.Howeveras
handsneedtobemobilisedafterthesurgerytopreventstiffness,woundbreakdown
canoccur,Ifaskingraftisneeded,thisisparticularlyfragile,andneedstobeprotected
asitheals.
©JamesHenderson2016