Dupuytren's Syndrome
NOTE: Dupuytren's condition occurs
because of contraction of the underlying tissue under the skin
leading to the finger curling up. It tends to run in families
and is more predisposed in the Northern European population.
Whilst this is not a cancer and therefore is not life threatening,
it can cause a great deal of disability to an individual patient,
for which they seek an opinion.
I tend to undertake surgery when the condition becomes a
hindrance. This usually involves when the knuckles (or MCP)
joints are contracted at least 25º or there is equivalent
contracture of the finger knuckles (PIP joints). This is when
patients complain of difficulty putting the hand into the trouser
pocket and the finger gets in the way when washing the face.
Surgery is not undertaken for pain felt over the nodules because
the scarring of the surgery can lead to painful scars. It is
only undertaken when there is a significant hindrance to the
patient because there is a rare risk of rapid recurrence called a
flare reaction which does occur in the occasional patient and
consequently, I believe the patient needs to be certain in mind
that the problem is significant to them such that should this occur
they feel that it has been worthwhile at least attempting the
surgery.
Surgery involves an operation and a tourniquet and consequently
because of the pain at the tourniquet, I prefer to do it under
general anaesthetic.
Risks to be aware of
Significant risks for the surgery which need to be taken into
account, the most important one being the risk of infection which
can lead to readmission to hospital, IV or oral antibiotics,
regular dressings or even a return to theatre for debridement
(clean-up). On occasions because of this the wound is left
open and will take several weeks to heal but usually this is not a
major problem. The main problem of infection apart from the
chance of being readmitted and requiring further surgery is the
risk of scarring around the infected site which leads to a
recurrence of the condition. This is the most common
complication, and occurs approximately 1 in 20 patients, but
usually if treated early does not cause too much of a problem.
A rare complication is the risk of nerve damage. The
Dupuytren's tissue is such that it surrounds the nerves leading to
it being entwined in the lesion itself. The operation
involves careful dissection out of these nerves to protect
them. However, there is a risk of a nerve being
injured. Should this happen it usually is repaired. It is
quite often that patients do not even notice a complication from
it. The worst case scenario would be a permanent loss of some
sensation over the part of the finger, but would not affect
movement of the finger.
Another factor is the risk of vascular injury. Certainly,
the surgery involves dissection of the neurovascular bundles out
and post surgery the finger can remain white for some minutes after
release of tourniquet. There is a potential risk of the
finger remaining permanently ischaemic, i.e., without blood supply
which will lead to the finger dying off and loss of the
finger. This risk is extremely low and in my practice I have
not seen this complication, but it is worth noting it as this is a
significant factor.
Finally, it is important to mention the risk of
recurrence. Whilst the quoted incidence of recurrence in the
literature is 20%, in reality, the majority of people will always
have recurrence if they live long enough. This means that
someone may, if they had a life expectancy of, taking to extreme,
of 200 years they would always get a recurrence. In reality,
only one in five people get a recurrence because it takes many
years to recur and most people will die of old age before they see
a significant recurrence.
The procedure
The surgery involves general anaesthetic and a tourniquet which
often is on for about an hour. Incision is along the line of
the tendons identifying the nerves and then zigzags into the
fingers. At the end of the procedure, I often do a zigzag in
the palm what we call Z-plasty to give the skin more length.
The nerves are carefully dissected out and the Dupuytren's tissue
is released. Sometimes, I need to release the capsule along
the knuckle closest to the base of the finger called the PIP
joint. If there is any concern about circulation, a boxing
glove dressing is placed on, otherwise a plaster is applied which
is used for two weeks. At about ten days we check the wound,
remove the sutures, get the finger moving and use a night splint
for the following four to six weeks. Often splints are
required and regular occupational therapy is used to maintain the
correction. It is an intensive process following surgery and
requires a good patient who is co-operative. The risk of
infection is reduced by ceasing smoking before and for the weeks
after the surgery and if there is any concern I always advise the
patient to return to contact me immediately and if for some reason
(unlikely) that I am not contactable, present to the nearest
hospital.
INFORMATION
LEAFLET TO PATIENTS REGARDING DUPUYTREN'S SURGERY
NOTE: Dupuytren's condition
occurs because of contraction of the underlying tissue under the
skin leading to the finger curling up. It tends to run
in families and is more predisposed in the Northern European
population. Whilst this is not a cancer and therefore
is not life threatening, it can cause a great deal of disability to
an individual patient, for which they seek an opinion.
I tend to undertake surgery when the
condition becomes a hindrance. This usually involves when the
knuckles (or MCP) joints are contracted at least 25º or
there is equivalent contracture of the finger knuckles (PIP
joints). This is when patients complain of difficulty putting
the hand into the trouser pocket and the finger gets in the way
when washing the face. Surgery is not undertaken for pain felt over
the nodules because the scarring of the surgery can lead to painful
scars. It is only undertaken when there is a significant hindrance
to the patient because there is a rare risk of rapid recurrence
called a flare reaction which does occur in the occasional patient
and consequently, I believe the patient needs to be certain in mind
that the problem is significant to them such that should this occur
they feel that it has been worthwhile at least attempting the
surgery.
Surgery involves an operation and a
tourniquet and consequently because of the pain at the tourniquet,
I prefer to do it under general anaesthetic.
Risks to be aware
of
Significant risks for the surgery which
need to be taken into account, the most important one being the
risk of infection which can lead to readmission to hospital, IV or
oral antibiotics, regular dressings or even a return to theatre for
debridement (clean-up). On occasions because of this the wound is
left open and will take several weeks to heal but usually this is
not a major problem. The main problem of infection apart from the
chance of being readmitted and requiring further surgery is the
risk of scarring around the infected site which leads to a
recurrence of the condition. This is the most common complication,
and occurs approximately 1 in 20 patients, but usually if treated
early does not cause too much of a problem.
A rare complication is the risk of nerve
damage. The Dupuytren's tissue is such that it surrounds the nerves
leading to it being entwined in the lesion itself. The operation
involves careful dissection out of these nerves to protect them.
However, there is a risk of a nerve being injured. Should this
happen it usually is repaired. It is quite often that patients do
not even notice a complication from it. The worst case scenario
would be a permanent loss of some sensation over the part of the
finger, but would not affect movement of the finger.
Another factor is the risk of vascular
injury. Certainly, the surgery involves dissection of the
neurovascular bundles out and post surgery the finger can remain
white for some minutes after release of tourniquet. There is a
potential risk of the finger remaining permanently ischaemic, i.e.,
without blood supply which will lead to the finger dying off and
loss of the finger. This risk is extremely low and in my practice I
have not seen this complication, but it is worth noting it as this
is a significant factor.
Finally, it is important to mention the
risk of recurrence. Whilst the quoted incidence of recurrence in
the literature is 20%, in reality, the majority of people will
always have recurrence if they live long enough. This means that
someone may, if they had a life expectancy of, taking to extreme,
of 200 years they would always get a recurrence. In reality, only
one in five people get a recurrence because it takes many years to
recur and most people will die of old age before they see a
significant recurrence.
The
procedure
The surgery involves general anaesthetic
and a tourniquet which often is on for about an hour. Incision is
along the line of the tendons identifying the nerves and then
zigzags into the fingers. At the end of the procedure, I often do a
zigzag in the palm what we call Z-plasty to give the skin more
length. The nerves are carefully dissected out and the Dupuytren's
tissue is released. Sometimes, I need to release the capsule along
the knuckle closest to the base of the finger called the PIP joint.
If there is any concern about circulation, a boxing glove dressing
is placed on, otherwise a plaster is applied which is used for two
weeks. At about ten days we check the wound, remove the sutures,
get the finger moving and use a night splint for the following four
to six weeks. Often splints are required and regular occupational
therapy is used to maintain the correction. It is an intensive
process following surgery and requires a good patient who is
co-operative. The risk of infection is reduced by ceasing smoking
before and for the weeks after the surgery and if there is any
concern I always advise the patient to return to contact me
immediately and if for some reason (unlikely) that I am not
contactable, present to the nearest hospital.
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