Dupuytren contracture

Dupuytren’s Contracture Surgery

Indications

Surgical treatment is indicated in patients with:

• Functional impairment affecting daily activities (e.g., inability to place the hand flat on a table – tabletop test positive).
• Metacarpophalangeal (MCP) contracture ≥ 30° and/or proximal interphalangeal (PIP) contracture ≥ 20° that does not improve with non-surgical methods.
• Disease progression despite conservative treatments such as splinting, collagenase injection, or needle aponeurotomy.
• Recurrent contractures after previous interventions.
• Severe skin involvement that requires dermofasciectomy and skin grafting.

Contraindications

• Early-stage disease without significant contracture.
• Severe joint stiffness or ankylosis, where surgery is unlikely to restore motion.
• Active infection in the hand.
• Severe vascular compromise or Raynaud’s disease, increasing the risk of poor wound healing.
• Poor general health preventing safe anesthesia and postoperative rehabilitation.

Preoperative Preparation

• Detailed hand examination (assess contracture severity, nodules, cords, neurovascular status, and skin quality).
• Preoperative imaging (optional): Ultrasound or MRI to assess deep involvement.
• Inform the patient about risks, potential need for skin grafting, recurrence rates, and rehabilitation commitment.
• Hand therapy referral for preoperative assessment and planning postoperative rehabilitation.
• Preoperative marking of neurovascular structures if needed (e.g., using ultrasound in severe cases).

Special Instruments, Position, and Anesthesia

Special Instruments

• Magnifying loupes for better visualization of nerves and vessels.
• Fine-tipped forceps and scissors for careful dissection.
• Blunt retractors to avoid nerve and vascular injury.
• Tourniquet for a bloodless field.
• Microvascular instruments if vessel repair is needed.

Position

• Supine position with the arm placed on an arm board.
• Hand supinated and fingers extended.
• A sterile tourniquet applied to the upper arm.

Anesthesia

• Regional anesthesia (Wrist or Axillary Block) – preferred for better postoperative pain control.
• General anesthesia – used if regional anesthesia is contraindicated.

Operative Technique & Approach

Surgical Approaches

1. Limited Fasciectomy (Most Common):
   • Z-plasty or longitudinal incision along the involved cord.
   • Careful dissection to preserve neurovascular bundles.
   • Resection of fibrotic cords while sparing essential structures.
   • Wound closure with skin flaps or grafting if needed.
2. Dermofasciectomy (For severe cases or recurrence):
   • Excision of diseased fascia along with overlying skin.
   • Full-thickness skin grafting to cover the defect.
3. Percutaneous Needle Fasciotomy (Minimally invasive option for selected patients):
   • Uses a needle to transect cords percutaneously.
   • Lower morbidity but higher recurrence rates.
4. Open Palm Technique (McCash Procedure):
   • Wounds left partially open to heal by secondary intention.
   • Useful in cases with high skin tension.

Tips and Pearls

• Mark neurovascular structures preoperatively using ultrasound if needed.
• Use magnification (loupes) for precise dissection.
• Elevate skin flaps carefully to avoid injury to nerves and vessels.
• Work in layers to minimize trauma and prevent unnecessary fibrosis.
• Consider leaving the skin partially open (open-palm technique) in severe cases.
• Early postoperative mobilization reduces stiffness.

What to Avoid

• Excessive dissection, which may damage the neurovascular structures.
• Complete excision of all fascia, as unnecessary excision increases complications.
• Overtight closure, leading to compromised skin viability.
• Inadequate release of PIP joint contractures, which are prone to recurrence.
• Failure to address recurrent cases with dermofasciectomy, which reduces recurrence rates.

Postoperative Care Issues

• Hand elevation and icing to reduce swelling.
• Early mobilization with supervised physiotherapy to prevent stiffness.
• Splinting in extension to maintain surgical correction (especially for PIP joint involvement).
• Wound care (if skin grafting was performed).
• Pain management with NSAIDs or regional anesthetic catheters.
• Follow-up schedule: Weekly dressing changes, stitch removal at 10–14 days, and long-term monitoring for recurrence.

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