Options for severe recontracture: recurrent Dupuytren contracture

The worst and unsolved part of Dupuytren contracture is recontracture after treatment, and then recontracture after retreatment. Most people don't have this problem, but when they do, the most common joint to have this problem is the small (pinky) finger PIP joint - the joint in the middle of the finger.

Recontracture after a minimally invasive treatment is often treated with fasciectomy (the most common open surgery), but what are the options when there is severe recontracture after fasciectomy? There are 3 traditional options recommended by hand surgeons.

1. Dermofasciectomy. This operation involves removing Dupuytren tissue and old scar tissue and replacing the skin of the front (palm) half of the finger with skin graft. It has the best chance of long term control, but has 3 potential problems:

• The complication rate is higher than for fasciectomy, but this is actually because the complication rate goes up with every redo surgery, and dermofasciectomy is often done as the second or third operation. The fewer operations before dermofasciectomy, the better.
• The previously operated finger may have so much scarring of the blood vessels that when the surgeon releases everything and tries to straighten the finger, it may start to cut off the circulation. If that happens, it limits how much improvement the surgery can give.
• PIP joint (the knuckle you use to knock on a door) contractures greater than 60 degrees tend to stretch out the tendons on the back of the knuckle which straighten the joint and at the same time shrink the ligaments on the front side of the joint. These issues are hard to perfectly correct even with surgery: the finger may be brought back to a straight position in the operating room, but relapse over the weeks that follow into a stiff bend, despite everything the surgeon, patient and therapist can do. Frustrating.

2. PIP joint fusion. Fusion (or arthrodesis) is removing the joint and making the two bones grow together to form one bone. It's usually done through a cut on the back of the finger, avoiding the battleground of the previous surgery to reduce the risk of nerve and circulatory injuries. The advantage is that the joint will not contract again. The disadvantage is that the joint won't bend again. Normally, the PIP joint is fused in a partial bend - as bent as it can be without catching on things, which really depends on how bent the next joint back is - the MCP joint (the knuckle you use to punch something). There are 3 issues with this operation:

• There's no perfect angle for a fused PIP - you have to choose between not catching it on things or not making a fist. Some people see fusing the joint bent as not much better than what they already have.
• It shortens the finger quite a bit, because the flesh on the palm side of the finger won't stretch out. It doesn't bring the finger back out to its original length.
• It makes a strange grip, because the joint doesn't bend where it used to.

Amputation. Only a consideration if requested by the patient because they have just had it with the finger and want to move on. If you're not at this point, amputation isn't for you. 

I'll review two newer procedures in the next post. 

Dupuytren's: it's not just the fascia.

Dupuytren's contracture is a local manifestation of a systemic process, and although the palmar fascia is the usual focus, what happens in the hand is a regional process, affecting the skin and the fatty layer under the skin as well as the fascia: it appears to be something which brews between the skin and the fascia, not just in the fascia. This concept and its consequences were eloquently reviewed by the late, great John Hueston in "The role of the skin in Dupuytren's disease" (full text: http://www.dupuytrenfoundation.org/DupPDFs/1985_Hueston_1125.pdf). His observations regarding the anatomy ("A nodule is never found on the dorsal aspect of a palmar aponeurosis..."), the biology ("...obsession with the collagenous structure of the palmar tissues is at present being replaced by the more logical study of the cellular origins..."), and the logic of dermofasciectomy and full thickness skin graft for aggressive or recurrent Dupuytren's are even more relevant today than when the article was published 25 years ago.

Dermofasciectomy reconsidered

There are three mechanical approaches for Dupuytren's. In order of both increasing problems and long term effectiveness, these are: fasciotomy (cut fascia); fasciectomy (remove fascia); dermofasciectomy (remove both skin and fascia). The popularity of dermofasciectomy and skin grafting has been limited by concerns regarding complications of wound healing and loss of flexion. Some of these concerns stem from the historical use of dermofasciectomy as a revision procedure after failed fasciectomy, a group biased toward poor results. Dermofasciectomy as the primary or first operation is a different story. This study reviews technical tips for dermofasciectomy and shows that for patients with diffuse skin involvement, primary dermofasciectomy and skin grafting has a better chance of long term control than fasciectomy. http://www.dupuytrenfoundation.org/DupPDFs/2000_Armstrong_1046.pdf