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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. |
| Click on each
image
for a larger picture |
| 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. |
| 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: |
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. |
| One week postop with typical full thickness skin graft bruising: |
| Two weeks postop, suture removal: |
| Six weeks postop. The skin graft is healed and sensation is near normal. Expected issues are difficulty restoring flexion. |
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