Surgery for Dupuytren Contracture Periprocedural Care

Updated: Nov 04, 2019
  • Author: Steve Lee, MD; Chief Editor: Harris Gellman, MD  more...
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Periprocedural Care

Preprocedural Planning

Various incisions can facilitate exposure during surgery for Dupuytren disease. [15]  Incisions can be transverse, longitudinal, or combined, depending on the pattern of involvement.

For a single digit, a midline volar incision closed with multiple Z-plasties can be employed. Some authors believe that a midline digital incision is least likely to expose a neurovascular bundle to injury. Alternatively, a volar zigzag incision or V-Y plasty can be used. [16]  Overall, digital Z-plasty incisions have been shown to give excellent exposure and functionally stable scars. [6]

For palmar disease with multiple MCP flexion contractures, a transverse incision at the level of distal palmar crease can be made. This can be joined to longitudinal digital incisions if necessary. Part of the palmar incision(s) can be left open, as in McCash’s open technique. Alternatives for palmar disease include palmar V-Y plasty.

Safe dissection during surgery for Dupuytren disease is enhanced by the use of loupe magnification. Sharp dissection is usually employed in separation of skin from the underlying diseased fascia. Dissection of the skin from the underlying fascia may leave very thin skin flaps, particularly in the digits.

If skin grafts are employed in the digits, they should extend from midlateral line to midlateral line across the digit.

In a severely involved digit, the neurovascular bundle may be most easily located distally. Dissecting retrovascular disease is important. Awareness of possible displacement of the neurovascular structures is essential.

Proximal division of the pretendinous cord may facilitate dissection by allowing finger extension and abduction.

In planning reoperative surgery for Dupuytren disease, if clinical evaluation suggests that the digital nerve has been severed, one should assume that the related digital artery has also been severed and should confirm adequate contralateral circulation to that digit.

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Patient Preparation

The surgeon, the patient, or both may choose either regional (local, median, or ulnar nerve block) or general anesthesia for the procedure. Regional anesthesia performed more proximally decreases tourniquet-related discomfort. Hurst has used bupivacaine HCl without epinephrine for its longer duration of nerve blockage. (Note that regional anesthesia should not be used if the patient has any of the following conditions: coagulopathy, psychosis, peculiar or unstable personality, or progressive neurologic disease.)

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