Case of open aponeurectomy, treatment of Dupuytren’s disease
Dupuytren’s disease is characterized by the formation of fibrous tissue (also known as fibromatosis) under the skin of the hand, leading to gradual contraction of one or more fingers towards the palm. The origins of this condition are many and varied, including familial predisposition. However, despite its first description by Baron Guillaume Dupuytren in 1832, the precise origin of the disease remains unknown.
- Laponectomy (removal of pathological fibrous fascia) is recommended when finger retraction prevents the hand from lying flat. An alternative to this procedure is simple aponevrotomy (section of the fibrous flange), which may offer temporary efficacy but leaves the fibrosis in place after simply severing the flange.
- No essential pre-operative investigations are required to confirm the diagnosis of Dupuytren’s disease. As a general rule, an MRI or ultrasound scan is not required prior to surgery.
Procedure for intervention
- The anesthesia generally used is locoregional, and surgery is commonly performed on an outpatient basis.
- The operation involves one or more discontinuous or sinuous incisions to achieve the most complete possible removal of the fibrous tissue that characterizes Dupuytren’s disease.
Sometimes, another transverse incision in the palm is added, and this is left open at the end of the procedure (the so-called “Mac Cash” technique) to loosen the scar when the skin closes. In any case, your surgeon will explain the technique required before the operation, the duration of which varies according to the extent of retraction and the number of fingers to be treated.
Dissection is performed gradually, protecting the vessels, nerves and tendons of the hand, and in cases of recurrence, a skin graft may be considered.
- Risks during the procedure mainly relate to potential damage to the blood vessels or nerves of the hand, which are in close contact with the fibrous tissue to be removed. This can lead to altered sensitivity or even loss of sensitivity after the procedure.
- Post-operative complications are generally rare, and rarely include infection. In exceptional cases, ischemia or even necrosis of the finger may occur, particularly in very severely retracted forms that may require amputation. However, skin problems are more common, ranging from simple delayed healing due to dampness to necrosis of the skin around the scar. Hematomas can also form, underlining the importance of monitoring dressings. The scar resulting from the operation tends to remain fibrous, but will gradually improve with time and rehabilitation to make the hand more supple. In some cases, the hand may become swollen, warm and painful, with a risk of stiffening of the fingers, a complication known as algodystrophy. The exact origin of this complication is poorly understood, and it can occur at random. The most frequent long-term complication is recurrence of Dupuytren’s retraction, which can occur several years after the operation, and even up to ten years later.
- After surgery, Dressings should be applied regularly until the skin has healed, especially if the palm is left open. Rehabilitation, which is not systematic but is frequently suggested, is usually started soon after the operation. A dynamic extension splint may be prescribed, to be worn discontinuously for one to two months post-operatively, according to the surgeon’s instructions.
- When the shrinkage is very important before the operation, it is frequent from do not recover totally the extension from or from fingers.
Your intervention at practice :
- Prior to surgery to treat Dupuytren’s disease, careful preparation is required, particularly for retracted forms. This involves carefully cleaning folds and areas prone to maceration to keep the skin dry and clean. It is imperative to considerably reduce or even completely stop smoking (including electronic cigarettes) prior to the procedure, preferably six weeks beforehand. Smoking increases the risk of post-operative complications. If you are diabetic, it is also important to monitor your blood sugar levels.
- The operation is generally performed on an outpatient basis, which means you’ll be able to go home a few hours after surgery. However, you will need someone to drive you home. After the operation, an initial dressing will be checked within 24 to 72 hours. It’s essential to plan in advance for the care needed to change dressings, choosing care close to your home.
- In the days following the operation, it is advisable to wear a sling to avoid placing the hand downwards. This helps prevent hand edema and swelling, which can lead to hand stiffness.
