Palmar fasciectomy (Dupuytren's contracture surgery)

About Dupuytren's contracture surgery

The procedure most commonly used to correct Dupuytren’s contracture is fasciectomy. This involves cutting open the skin on the palm of your hand and fingers and removing the underlying tissue that has become thickened and tight and is causing your fingers to stay bent inwards. This tissue appears as ‘cords’ under the skin of your hand.

What are the alternatives to Dupuytren's contracture surgery?

There are alternatives to fasciectomy. A new procedure involving injecting collagenase (Xiapex) into the cords has recently been approved for use in the UK. Collagenase is an enzyme that can break down the cords that are pulling your fingers inwards. You will have the procedure done as an outpatient. This means you can go home after having the injection, but you will need to return the next day to have your fingers carefully manipulated by your surgeon. This is to try to make the cord break.

You won’t need to have an anaesthetic if you have collagenase injections.

Needle fasciotomy is another outpatient, day-case procedure that is carried out under local anaesthesia. This means you will be awake but the pain from your hand will be completely blocked. This technique involves using a needle to divide the cords that are causing the bending of your fingers. Although this is a less complex procedure than fasciectomy and recovery time is usually shorter, there is a high risk of the contracture coming back after treatment.

Preparing for Dupuytren's contracture surgery

Your surgeon will explain how to prepare for your procedure. For example, if you smoke you will be asked to stop, as smoking increases your risk of getting a chest and wound infection, which can slow your recovery.

Fasciectomy is usually done as a day-case procedure. This means you have the procedure and can go home the same day. The operation is done under regional or general anaesthesia. Regional anaesthesia means that the pain and feeling from your whole arm will be blocked, but you will stay awake during the operation. General anaesthesia means you will be asleep for the whole operation. Your surgeon will discuss your options with you.

At the hospital your nurse may check your heart rate and blood pressure, and test your urine.

Your surgeon will discuss with you what will happen before, during and after your procedure, and any pain you might have. This is your opportunity to understand what will happen, and you can help yourself by preparing questions to ask about the risks, benefits and any alternatives to the procedure. This will help you to be informed, so you can give your consent for the procedure to go ahead, which you may be asked to do by signing a consent form.

What happens during Dupuytren's contracture surgery

After the anaesthetic has taken effect, your surgeon will use a tourniquet (a band that can be inflated and deflated) on your upper arm to control the bleeding in your hand during the operation. Cuts will be made into the skin of your palm and along the affected fingers. You surgeon will probably use zigzag cuts because they minimise the tension on the skin after the stitches are put in and the wound begins to heal. The contracted cords from under your skin are removed from the palm area and fingers, allowing your bent fingers to return to a relaxed position. Your surgeon will close your wound with stitches and cover with a dressing.

This operation usually takes one to two hours.

A variation of this procedure is dermofasciectomy. You will probably have this procedure if your contracture involves your skin as well as the underlying tissue. It’s also recommended if you have severe disease or the contracture has come back after treatment. Dermofasciectomy involves removing not only the contracted cords but also the skin on top. After the cords and skin are removed you will need a skin graft to replace the skin and close the wound. This is usually taken from your upper arm or groin.

This operation usually takes about two hours and is done under general anaesthesia.

What to expect afterwards

You will need to rest until the effects of the anaesthetic have passed. You may feel sick or vomit if you have had a general anaesthetic. After a regional anaesthetic it may take several hours before the feeling comes back into your treated arm. Take special care not to bump or knock the area.

Your hand will be covered in a bandage and you may have a splint as well. You will be given a sling to wear. Ideally this should keep your hand above heart level so that your hand is kept nearer to your shoulder than your waist. This will help to prevent swelling. You can take the sling off at night.

You will need to arrange for someone to drive you home. If you had a general anaesthetic, you should try to have a friend or relative stay with you for the first 24 hours.

General anaesthesia temporarily affects your co-ordination and reasoning skills, so you must not drive, drink alcohol, operate machinery or sign legal documents for 24 hours afterwards. If you're in any doubt about driving, contact your motor insurer so that you're aware of their recommendations, and always follow your surgeon's advice.

Before you go home, a physiotherapist may visit you to discuss exercising your hand at home. Your nurse will give you some advice about caring for your healing wounds. You may be given a date for a follow-up appointment.

Recovering from Dupuytren's contracture surgery

If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen. Always read the patient information that comes with your medicine and if you have any questions, ask your pharmacist for advice.

For the first few days after your procedure, it‘s important to keep your hand and fingers still to allow the wound to heal. Keep your hand elevated in your sling as much as possible. If you have been given a splint to wear, it’s important that you use it as you’re instructed, which will probably be to wear it for some time during the day and all night for at least three months. When you aren’t wearing the splint, follow the advice from your physiotherapist about the types of exercises and movement you need to do to keep your fingers mobile. You may find that raising your hand on a pillow when you’re sleeping also helps to prevent pain and swelling.

If you notice signs of an infection, contact your surgeon. Signs of infection include:

  • swelling or increasing stiffness of your hand
  • redness or itchiness
  • increased heat from the wound
  • fluid or pus coming from the wound
  • fever

As far as possible, keep your wounds dry. Have showers instead of baths and take care not to let your wounds soak in water. This will help them to heal.

You will be given an appointment to have your stitches removed.

What are the risks?

As with every procedure, there are some risks associated with fasciectomy. We have not included the chance of these happening as they are specific to you and differ for every person. Ask your surgeon to explain how these risks apply to you. 

Side-effects

Side-effects are the unwanted but mostly temporary effects you may get after having the procedure. The side-effects specific to fasciectomy are pain, stiffness in your fingers and swelling, which should all lessen within a few weeks of having your surgery. You may temporarily have reduced feeling in your fingers that were operated on. The time it takes for full feeling to return varies from person to person.

Complications

Complications are when problems occur during or after the operation. Most people are not affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, infection and excessive bleeding.

Complications that are specific to fasciectomy are listed below.

  • Complex regional pain syndrome – a chronic pain condition with the key symptom being continuous, intense pain out of proportion to the severity of the injury. This is likely to get worse rather than better over time.
  • Damage to an artery or nerve in your finger.
  • Haematoma – this is a localised swelling filled with blood. This can be prevented and corrected during the operation.
  • Incomplete correction of the contracture, which may require further surgery.
  • Slow healing or necrosis (of skin or graft) meaning that the tissue dies instead of healing.

When will I be able to go back to work after Dupuytren’s contracture surgery (fasciectomy)?

Answer

When you decide to return to work will depend on a number of things, especially the job you do and which hand was operated on.

Explanation

If you had a general anaesthetic, you will probably need at least two days off work to recover from fasciectomy. How long you take off work will also depend on which hand was operated on, that is whether it was your dominant (writing) hand or your non-dominant hand. Also, the type of job you do will make a difference to how long you need away from work. For an office-based job you can probably return to light duties within a week, although typing could still be difficult. If you have a manual job, such as bricklaying or carpentry, you may need up to six weeks before your hand is healed enough to return to work.

Discuss with your occupational health department or human resources team (if your workplace has one) the arrangements for being away from work after an operation.

Will I have scarring and if so how much?

Answer

Yes, from this type of surgery, you will have a scar in the palm of your hand and along your fingers.

Explanation

Your surgeon will probably make zigzag cuts to open up the skin of your palm and fingers so that the tight underlying tissue (the cords) can be removed. These zigzag cuts are more effective for promoting good healing of your skin because they will not pull tight as the scar heals. The scar can be quite large from this surgery and you will likely be given a splint to wear to help the skin heal correctly. Follow the instructions you are given by your surgeon or nurse about caring for your healing wounds to have the best chance of minimal scarring and to reduce the risk of other problems such as an infection.

What is the success rate for this surgery?

Answer

There are many factors that can affect the how effective fasciectomy is for treating Dupuytren’s contracture. In most people their fingers can be fully or nearly fully corrected by having this surgery.

Explanation

The length of time that you have had Dupuytren’s disease will affect the result of this surgery. The longer your fingers have been bent, the lower the chance is of surgery being able to completely correct this. The success of the surgery will also depend on which joints are involved. There is some evidence that the nearer to the palm the affected joint is, the better the outcome. In addition, how severe the bending of your fingers is will affect how well the surgery works. Less bent fingers have a better chance of being straighter after surgery. If your fingers are severely bent into the palm of your hand, surgery can straighten your fingers somewhat but it may not be possible to get them fully straight.

Dupuytren’s disease is a progressive condition, meaning that it gets worse over time. Even after successful surgery the contracture can come back.

For all these reasons it’s best to seek medical advice sooner rather than later with Dupuytren’s disease as this gives the highest chance of a result you will be happy with. If you’re thinking about surgery, you need to discuss these factors with your surgeon before giving your consent.