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DUPUYTREN’S CONTRACTURE

 

Dupuytren’s disease is a disease of fibres that hold the palmar skin to the underlying tissues.  This allows humans to grip objects without the skin of the palm slipping.  This is a common disease in Northern Europeans and is said to originate from the Vikings.  This is often inherited and can also affect the feet.  It commonly affects men in the middle ages and its onset may be accelerated by trauma.

 

A band or nodule usually arises in the palm of the hand.  This nodule then gradually progresses to becoming a band that pulls the ring, little and the middle finger down into the palm of the hand.  This can affect other areas in the hand. This can occur elsewhere in the body. 

 

 

 

 

 

Treatment-  May be required depending on the stage of the disease. 

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Collagenase Injections: This is a treatment Mr Khandwala has been using for about 2 years. An enzyme that dissolves the collagen fibres of the contracture is injected directly into the fibres. A few days later the finger is manipulated to break the cord and achieve a straighter finger. 

            This is a painful injection but spares the patient surgery and can be a good first line treatment prior to considering surgery. Recovery is quicker but there is not enough evidence on the incidence of recurrence following this injection.

Complications include swelling, Bruising, Skin break, with a rare chance of tendon or pulley rupture if this is inadvertently injected into a tendon. ( THESE INJECTIONS ARE NO LONGER AVAILABLE)

 

Needling: In some cases a selective procedure called ‘needling’ can offer good temporary relief from the effects of the contracture.  This is performed under local anaesthetic as an outpatient procedure. Nerve damage is more common with this procedure and recurrence is very likely. 

 

Fasciectomy and Dermofasciectomy

 

In some patients surgery may be required to cut out the diseased tissue.  The skin is often refashioned using a zigzag incision.  Occasionally in very aggressive cases a skin graft from the forearm or the inside of the arm may be used. When the diseased skin of the palm is replaced with skin from elsewhere the operation is called a Dermofasciectomy. 

 

Possible complications after surgery for Dupuytrens contracture: Complications can occur with any operation, they are, however, quite rare with carpal tunnel syndrome.  Complications can include 

 

Nerve damage.  Nerves to the finger are intimately related to the duputrens tissue and may be compressed by the process or suffer damage during surgery.

This can result in numbness in the finger and can occasionally lead to pain. Recovery from nerve damage can take upto two years and may be incomplete

 

Bleeding, infection and loss of skin can occur and is more common in smokers. Some Scarring will always occur in all the operated sites and this can be variable

 

Stiffness can occasionally be a problem and exercises are prescribed in the early days to ensure that stiffness does not occur.  It is very important to carry out these exercises.

 

Cold intolerance:  The hand can be insensitive to cold weather for a few years following surgery.  This is especially true in smokers. 

 

Nerve recovery can take up to three years depending on the age group of the patient.  In most patients without permanent nerve damage the sensation is normal and symptomatic relief is almost immediate.

 

Loss of power.  There is a weakness of the hand following this surgery.  This generally improves over the next six to nine months as the scar remodels and becomes stronger.

 

Chronic regional pain Syndrome: This is unpredictable and occurs in a small percentage of patients that have surgery or injury. This is a reaction of the nerves and blood vessels. Anyone can get this  despite  good treatment. Some patients react to injury or surgery in this way and recovery can be prolonged and protracted. One may never recover completely.

 

Recurrence: The fibres of dupuytens disease can grow back. Fibres that are unaffected by the process are not removed during surgery and these can grow into dupuytrens tissue. The most reliable operation for recurrent disease is a Dermofasciectomy

 

Dermofasciectomy: This  operation entails the removal of skin and Dupuytren’s tissue involved in the disease and its replacement with a skin graft from the arm or forearm. This non-native skin acts as a firebreak reducing the chances of a recurrence

 

 

Aftercare following Dupuytren’s Fasciectomy – the aftercare is mainly determined by the nature of the operation.  The patient is normally encouraged to use his hand after the operation and is required to wear a splint only at night.  Mr Khandwala normally uses dissolving sutures to close these wounds.  A therapist is usually assigned to look after the patient.  Mr Khandwala will advise you on the time to start driving and getting back to normal activities.  In cases where a skin graft has been used, recovery may be longer.  

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