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Dupuytrens Fasciectomy A guide for patients Gateshead Upper Limb Unit Andreas Hinsche John Harrison Jagannath Chakravarthy Page 1 of 6 What is Dupuytren’s Contracture? Dupuytren’s contracture is a condition that affects the hands and fingers. It causes one or more of the fingers (on one or both hands) to bend into the palm of the hand. This is not a condition affecting the tendons (guides that allow us to bend and straighten our fingers) How common is Dupuytren's contracture? Dupuytren's contracture is a fairly common condition. It tends to affect more men than women, and often occurs in later life. It can affect up to 20% of men above 60, and 20% of women who are over 80 years old. Dupuytren's contracture is most commonly found in white Europeans, and it is believed to run in families. What do we know about it? Research has failed to reveal the exact cause of this condition but we know that It is benign ( ie not cancerous) It can run in families It is commoner in diabetics/ smokers/ people on certain anti-epileptic medications and people using vibration tools It is more aggressive if it affects both hands or the thumb and index finger. Also if it affects young patients. It is a progressive condition. If one or more fingers become permanently bent, it can make daily activities, such as buttoning up a shirt, difficult. There is no cure What are the symptoms It is usually a painless condition though it can be painful in the initial stages It starts off as nodules (small growths or lumps of tissue) that appear in the palm. One might find the skin to be pitted ( like dimples) around the nodule. Over time, the nodules can grow Page 2 of 6 into cords of contracted (shortened) tissue. As the tissue contracts, it becomes difficult to fully straighten the finger, which eventually becomes permanently fixed in a flexed (bent) position. What are the treatment options The treatment depends on the severity of the deformity of the fingers Leaving it alone and observation over time is best for patients with mild deformities, isolated nodules and in patients with minimal functional limitation. Needle / Percutaneous fasciotomy is occasionally indicated for patients with isolated deformity of the knuckle joint. It involves using a needle or knife to snap the band causing the deformity. This is usually done under local anaesthetic. Recurrence rates are high Fasciectomy involves removing all visible dupuytren’s tissue . This requires a fairly long incision over the palm. This has the least recurrence rates. Injections are a new treatment which are not yet available in the trust as it is still experimental. The injection has a drug which weakens the band which is then snapped straight in the outpatient clinic Why do I need an operation? The main reason why surgery is necessary is to prevent further flexion (bending) of the affected fingers as this will restrict the function of your hand. The flexion deformity not only becomes a nuisance but can be dangerous in some occupations or activities. If the deformity is not corrected early enough then successful release is less likely and in some cases amputation of the affected fingers is the only alternative. What does the operation involve? The operation consists of having an anaesthetic, usually a general anaesthetic, that puts you to sleep, but on occasions a “nerve block” which “numbs” the affected arm is used as an alternative. The procedure involves removal of the tight tissue band/s causing the deformity. You will have one or more incisions in your hand, these wounds are usually stitched in a zigzag manner. In some cases a skin graft may be required, where a patch of Page 3 of 6 skin from the forearm or wrist is grafted into the scar. During the first three days after surgery it is normal to have a bulky dressing in place (like below) and a high sling to reduce the risk of bleeding or swelling. What happens before the operation? Prior to admission you may need to have a pre-operative assessment. This is an assessment of your health to make sure you are fully prepared for your admission, treatment and discharge. Before the date of your admission please, read very closely, the instructions given to you. If you are undergoing a general anaesthetic you will be given specific instructions about when to stop eating and drinking, please follow these carefully as otherwise this may pose an anaesthetic risk and we may have to cancel your surgery. You should bath or shower before coming to hospital. Please trim your nails and keep your hands clean. Remove any rings your might have on the operation side. The surgeon and anaesthetist will visit you and answer any questions that you have. You will be asked to sign a consent form. A cuff will be put on your arm, some leads placed on your chest, and a clip attached to your finger. This will allow the anaesthetist to check your heart rate, blood pressure and oxygen levels during the operation. A needle will be put into the back of your hand to give you the drugs to send you to sleep. How long will I be in hospital? You may be admitted as a day patient, when you will be able to go home shortly after the operation. Alternatively you maybe admitted to the ward, either on the day of your operation or the day before. You are usually ready to go home within 24 hours following your surgery. If you are an in-patient you may be seen by the physiotherapist and you may be given exercises within your bandage. It will also be necessary for you to attend the hospital for outpatient physiotherapy once your stitches have been removed. Page 4 of 6 What complications can occur? This leaflet describes only the more common or serious complications. Infection is always a possibility following any surgical procedure, therefore it is very important to keep the dressings clean and dry. Infections are easily treated with antibiotics.If you feel your dressing needs changing please contact the hospital via the numbers on the back of this leaflet. Bleeding from the wound may also occur and to minimise this it is therefore important to keep the hand elevated during the first 48-72 hours following your surgery. Nerve damage can occur because the nerves of the hand may be entwined around the cord. It is quite common to have some numbness or tingling in the finger for upto six weeks. The risk of nerve damage resulting in alteration or loss of some sensations to the fingers, this is a rare complication. Recurrence rates are 50% over 10 years on average. Most recurrences do not require surgery. What symptoms may I experience after my operation? After surgery you may experience stiffness and scar tenderness. With time and gentle use the stiffness should disappear, this is usually over 6 weeks to 3 months. The scar will remain pink for some time and gradually fade to a white line. There may be some discomfort and/or pain following surgery to the wrist but this can usually be controlled by simple painkillers. However, if your pain is severe and continuous you should contact your GP. Will I need Physiotherapy? You will be seen by the Physiotherapist after your surgery, either on the ward or shortly after your first out-patient appointment. Sometimes you may be seen when your dressing is first removed after surgery. Gentle finger movements may be commenced if your wound is satisfactory. A night splint will be required for 3 months. You will be seen again following removal of your stitches and physiotherapy appointments will be arranged. You will attend once or twice a week initially, when treatment will consist of exercises and scar management.. The timing of different treatments will depend on how quickly your wound heals, it is possible you may still require dressings even when you are receiving physiotherapy treatment. You will be advised when the wound is sufficiently healed to allow washing. Scar massage will be taught at this stage. When can I resume normal activities? Normal light use of the hand is encouraged once the wound is healed. Heavy and repetitive use should gradually be reintroduced. Be guided by your pain and any swelling in your hand. Driving Generally you are safe to drive when your wound is healed and you are free of your dressings, providing you have a good range of bend in the fingers and your hand is not too painful and tender. Page 5 of 6 Washing-up This should be avoided until the wound is healed, you may need to use a rubber glove initially as your hand may be a little sensitive to the heat of the water. Work Your return to work will be dependent on your recovery following surgery and the nature of your job. Most people return to work within 6-8 weeks although this may vary depending on your job, side of dominance, any complications and the rate of recovery of hand function. This should be discussed with your Consultant. Swimming If you are going on holiday then avoid swimming, especially in the sea, until the wound is fully healed. Where can I get further information? Your Consultant and GP will be able to answer most of your questions, as will the Orthopaedic Nurse Practitioners who will see you prior to your admission. Telephone numbers During the hours of 8am -8pm contact the Day Surgery Unit, North East NHS Surgery Centre, Queen Elizabeth Hospital 0191 4453009 During the hours of 8pm -8am contact Level 1, North East NHS Surgery Centre, Queen Elizabeth Hospital 0191 4453005 During the hours of 0800 -1630 contact the Physiotherapy Department (please ask for a member of the upper limb team) 0191 4452320 Main switchboard 0191 4820000 Data Protection Any personal information is kept confidential. There may be occasions where your information needs to shared with other care professionals to ensure you receive the best care possible. In order to assist us improve the services available your information may be used for clinical audit, research, teaching and anonymised for National NHS Reviews. Further information is available in the leaflet Disclosure of Confidential Information IL137, via Gateshead Health NHS Foundation Trust website or the PALS Service Information Leaflet: Version: Title: First Published: Last Reviewed: Review Date: Author: NoIL279 3 Dupuytrens Fasciectomy June 2010 November 2012 November 2014 Gateshead Upper Limb Team This leaflet can be made available in other languages and Page 6 of 6 formats upon request