Fasciectomy

Fasciectomy has been the mainstay of surgical treatment for many years. Probably originally described by Skoog shortly after the second World War, this has been the standard by which all others are measured. Whilst vast numbers of operations have been done all over the world, good quality surgical outcome studies are rare.
The surgery is usually carried out under General or Regional anaesthetic. In the Pulvertaft Hand Unit in Derby we do the vast majority of such surgery under a regional block with the patient awake or lightly sedated. This has major advantages in terms of sedation and should be discussed with your anaesthetist
A tourniquet is used to prevent bleeding during the dissection as the cord and nerves, tendons, etc are intimately associated and need to be visualised and protected during surgery.

The surgery can be done as either segmental fasciectomy or limited fasciectomy.

Segmental fasciectomy was described by Moermans back in 1991 although he credits Vilain in 1982 with the first description.

Segmental fasciectomy

Moerman developed segmental fasciectomy “to look for an operation allowing a simple post-operative course and a longer relief of the contracture than usually achieved by simple subcutaneous fasciotomies.”  He started in 1983 and when he published in 1991 he had done 213 operations and had well documented results.  His basic premise was to create “a permanent discontinuity in the retracted aponeurotic band without wide dissection of the fascia itself, then the retracted band (from which tension has been eliminated) will disappear or at least cease to act as a contracture.  McFarlane, the doyen of Dupuytrens surgery at the time, felt that this had not been proved in an accompanying editorial.

 Certainly segmental fasciectomy works.  It is a smallish operation which can even be done under local anaesthetic although regional block is more usual.

This is a full operation requiring a flap to open the skin, removal of 1cm segments of the cord and then closure of the skin with sutures.  Increasingly we are using absorbable sutures for this.  You then need a dressing and I would put a small splint on for a few days to hold the fingers straight.  Often the tissues will come out straight but they have adapted to being contracted so splinting them straight for a few days will help to overcome that learnt contraction.  

 

Limited fasciectomy

 

This is the most common form of surgery, in the UK.  Surgery is again done as a daycase and under regional anaesthetic. There are in general 2 approaches.  The first uses a zigzag incision to open the finger and the alternative, Skoog approach, uses a straight line cut down the finger and then converts this to a zigzag at the end of the operation.  The Dupuytrens is the removed, preserving the vessels and the nerves and the skin closed up.  Sometimes the skin in the palm is left open to allow blood to drain and to not put the tissues under too much tension.  This is the so called Mccash approach, although McCash actually described doing the whole operation through one cut in the palm.  Although the initial reaction to having a hole in your hand is generally “Yeucch”, the result is usually a painless wound which heals with a beautiful result in 2-3 weeks.  Again I am generally using absorbable sutures to close for ease and comfort.  Dressings tend to be a bit bulkier.

 

Why do we use a zigzag scar?

All scars shrink!  They shrink from end to end and therefore a straight scar from fingertip to palm will tend to pull the finger down into the palm again recreating the Dupuytrens contracture!  By zigzagging the scar we change the direction of this scar contracture and reduce the risk of recurrence.  There is also thought to be a theoretical advantage that the direction of pull of any remaining Dupuytrens tissue is also changed and thus the risk of recurrence is reduced.

 

Postoperative care

Immediately post op we encourage you to elevate the hand above heart level for the next 3-4 days.  I personally do not like slings as they are often at the wrong level and they encourage you to forget about the hand, whereas I want you to involve the hand as much as possible in daily use.

 

In the Pulvertaft we will remove the dressing at 5 days and the physiotherapist will encourage you to move the finger.  We will then provide a splint to be worn at night for 6 months.  I will generally expect you to be off work for upto 6 weeks depending on your job and requirements.

 

Complications

Any surgeon who tells you that he doesn’t have problems with these operations is either telling untruths or never sees his patients postoperatively!

The best paper I have found on this subject was written by Mr J Dias, Consultant Hand Surgeon in Leicester.  He sent a questionnaire to 1100 patients following their surgery to assess the rate of complications and patient satisfaction with the process.  He found that 75% had a good correction but 46% reported some form of complication.

 The Dupuytrens tissue can be very closely adherent to the skin and the plane between skin and cord difficult to define.  This means that sometimes the skin flap will end up too thin and have problems healing.  Usually the skin will heal but may take several weeks.

Infection is a problem in any operation but if you get a haematoma this vadstly increases the risk of infection.. Again this should settle with antibiotics but may take many weeks to heal.

A haematoma is a collection of blood inside the wound.  This is very painful and leads to problems with skin healing and infection.  The extra scarring can lead to early recurrence or to scar contracture mimicking recurrence.

Nerve damage is a common problem. I think this is actually commoner than many surgeons think.  We are very bad at actually assessing nerve problems and many patients simply accept the end result.

Sympathetic Dystrophy or complex regional Pain syndrome is rare, but devastating.  My consent form will tell you that it will leave you in so much pain (and stiffness) that you are unable to use your hand for 2 years. 

The table below lists the most common complications and the reported incidence for each complication.

 

 This table is taken from a paper presented at the American Society for Surgery of the Hand 2006.  Remember that these are the best results as nobody publishes their bad results.