Clinical Example: Dermofasciectomy and Full Thickness Skin Graft for Recurrent Dupuytren's Contracture

The treatment of Dupuytren's contracture bounded by factual constraints of its biology:
  • There is not a pharmacological cure.
  • Open surgery has significant risk of permanent complications, even for experienced surgeons.
  • Recurrence is common after surgery.
  • More radical surgery results in longer remission, but proportionally higher rates of complications.
  • Open surgery for recurrent Dupuytren's contracture has twice the complication rate of first time surgery, and recurrences may not be able to be treated with repeat surgery.
  • PIP contractures recurring after fasciectomy usually involve issues independent of Dupuytren's such as flexor sheath shortening and PIP capsuloligamentous contractures.
  • Recurrent PIP contractures occuring in the absence of clinical Dupuytren's disease generally do not progress after the first postoperative year.
In addition, there are personal observations that:
  • isolated small finger PIP contractures in women are so prone to rapid recurrence that dermofasciectomy should be considered as the first open procedure.
  • PIP fusion is a safer alternative to repeat palmar procedures for recurrent PIP contractures, but may require significant (1-2 cm) shortening. 

This case is presented to demonstrate some of the difficulties encountered in the treatment of recurrent Dupuytren's contracture.
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This woman has a recurrent small finger PIP contracture after two open fasciectomies by two other experienced hand surgeons over the last  18 months. Both procedures were followed by long periods of hypersensitivity and paresthesias. History is also significant for both Raynaud's and Von Willebrand's disease. Digital Allen's test indicated patency of both digital arteries. 
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Over the following year, she had progressive 75 PIP and 15 DIP contractures with Dupuytren's type soft tissue involvement, and the decision was made to manage this with dermofasciectomy and skin graft.  Here, the previous incisions are marked with dotted lines and the excision plan marked with continuous lines:
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This was a technically challenging operation:
  • The digital nerves were scarred and flattened against the flexor sheath.
  • The PIP joint contracture did not change after soft tissue excision and release of both the PIP volar plate and collateral ligaments.
  • PIP contracture at this point was clearly due to flexor sheath shortening and did not change until the distal A2 sheath was released, resulting in an 8mm gap of exposed flexor tendon.
  • An ulnar digital artery could not be identified.
  • The radial digital artery was folded in a scarred double hairpin curve at the PIP level and was inadvertently transected during dissection.  The fingertip was  avascular on tourniquet deflation, and only "pinked up " after microvascular repair.
The defect was covered with a full thickness skin graft harvested as a longitudinal lenticular excision from the proximal medial forearm. Full thickness skin grafts on a peripherally well vascularized bed can heal over a central avascular defect of up to one cm in diameter. In this case, the area of exposed flexor tendon was just small enough to avoid the need for altenate cover such as a dorsal cross finger flap from the ring finger. The PIP joint was pinned in 25 degrees of flexion, a compromise based on the summary of issues outlined.
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One week postop with typical full thickness skin graft bruising:
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Two weeks postop, suture removal:
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Six weeks postop. The skin graft is healed and sensation is near normal. Expected issues are difficulty restoring flexion.
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