Boyd W. Haynes III, MD
I’ve been around a while as an Orthopaedic surgeon, so when I first started practicing, there were only two ways to treat Dupuytren’s contracture, physical therapy or surgery. Pretty much all of us orthopaedic physicians did the surgical procedure in the old days – 30+ years ago. Now, mostly hand specialists take care of DP, although a few old guys like me will still take on simple cases. Thankfully, patients now have more, less-invasive options to consider when it comes to treatment and hand specialists who operate exclusively on their hands, every day!
Procedural Treatments – Both of these are done by Orthopaedic Hand Specialists
Enzyme Injections: The FDA approved Xiaflex® (Collagenase clostridium histolyticum) medication in 2010 as an injection that can be used to weaken the fibrous cords of tissue in the hand and fingers. This allows for manual manipulation of the hand and fingers to restore movement the day after the injection. A local anesthetic is also used during both the injection and the manual stretching to ease discomfort. The typical treatment regimen consists of three injections, and it’s effective in about half the people (44-64%) that receive them.
Needle Aponeurotomy (percutaneous needle fasciotomy): This minimally invasive procedure involves using a needle to punch holes into the cords of tissue restricting the fingers, making the cords weaker by breaking the bonds that strengthen them. As a result, the fingers are easier to bend. It’s done in an office setting, where the hand is numbed using a local anesthetic.
Recovery is quick. There will be adhesive bandages over the injection sites and the hand shouldn’t be fully submerged in water for two days. The hand can be iced for soreness intermittently, Tylenol taken for discomfort, and grasping should be avoided for a week to allow it to heal. Afterwards, a steroid may be injected into the hand to accelerate healing.
Surgery
Fasciectomy: This is probably the most common treatment for DP. It is outpatient surgery, minimally invasive in nature and very effective. I make an incision in the palm of the hand and remove the thickened tissue, allowing the finger to straighten. I perform this surgery at Coastal Virginia Surgery Center or at Mary Immaculate Hospital. Dr. Jeffrey Carlson at OSC also performs this procedure.
This surgery requires some recovery time (typically four weeks for full hand use), post-surgical elevation of the hand, intermittent icing, pain medication, using a sling for a week and keeping your incision clean and dry. Physical Therapy will probably be ordered to help you regain full motion in your hand and fingers.
Subtotal Palmar Fasciectomy: This surgery is for severe cases where several fingers are involved, and the contracture is significant. I typically refer these cases out to a hand specialist in the area because of the extensive nature of the surgery.
Recovery is more prolonged here and patients should expect to be in a sling for a period of several weeks. Physical Therapy will be very important to help the patient regain full range of motion and functionality.
Surgery is no guarantee that the problem won’t recur, and it sometimes does, unfortunately. For those patients, there is one remaining surgical option.
Dermofasciectomy: Reserved for severe or recurrent cases, the affected fascia along with the overlying skin is removed and then replaced with a skin graft. Not for the faint of heart, but necessary for some folks. This also is referred to an Orthopaedic Hand Surgeon.
This recovery is even more lengthy as it involves a skin grafting procedure. If the skin graft is autologous, add healing time to the area of the body from whence the donated graft was removed. If cadaver or pig skin was used, extreme care still must be taken while the graft heals in place, with specific instructions on elevating the hand, keeping the graft clean and dry, keeping a sterile dressing on the graft and managing any associated post-surgical pain.
Surgery with a skin graft is also more prone to complications, such as infection, graft shrinkage, loss of sensation, heightened pain, loss of circulation, etc.
Post-Surgical Physical Therapy
Once everything has healed sufficiently, post-procedural therapy will be crucial to regain and maintain hand flexibility and function. Exercises will be important to improve mobility and strength. Modalities like laser therapy can be very therapeutic for scar tissue and adhesions. Massage and manual therapy will also help to prevent the formation of more scar tissue and relax scarring over incision sites.
Splinting may also be recommended to keep fingers extended during recovery.