Dupuytren's Fasciectomy - Regional (Segmental) Fasciectomy

Step 1: Preoperative Assessment and Planning

TUBIANA CLASSIFICATION: Stage I (0-45 degrees), II (45-90 degrees), III (90-135 degrees), IV (greater than 135 degrees). Document total passive extension deficit (TPED) for each affected digit. Assess skin quality: blanching indicates ischemic skin (may need excision and grafting), puckering indicates adherence (difficult flap elevation), fixed skin indicates severe disease. Identify disease pattern by palpation: pretendinous cord (midline palm/digit), central cord (A1 pulley to middle phalanx), spiral cord (lateral digital sheet spiraling around digit - HIGH RISK for NVB displacement), natatory cord (web space), retrovascular cord (distal to NVB - EXTREMELY HIGH RISK). Mark diseased cords and planned incisions with surgical marker. Counsel patient regarding: nerve injury risk (3-5 percent overall, higher with spiral cord), recurrence risk (20-50 percent at 5 years, higher with diathesis), prolonged hand therapy requirements (3-6 months), realistic expectations for PIP correction (50-70 percent versus 80-90 percent for MCP).

Step 2: Positioning and Anesthesia

Position patient SUPINE with affected arm extended on radiolucent hand table. Arm abducted 90 degrees at shoulder. Hand table at appropriate height with sterile foam padding. Apply tourniquet to upper arm. General anesthesia or regional anesthesia (axillary block, Bier block, WALANT - wide awake local anesthesia no tourniquet). For WALANT: infiltrate 1 percent lidocaine with 1:100,000 epinephrine along planned incisions (20-30 minutes before incision for vasoconstriction). Inflate tourniquet to 250mmHg for upper arm (100mmHg above systolic). Exsanguinate with Esmarch bandage or elevation. Position loupe magnification (2.5-3.5x power strongly recommended for identifying neurovascular structures). Prepare and drape entire hand and forearm. Final check of marked incisions and diseased cords before skin incision.

Step 3: Skin Incision Design and Execution

BRUNER ZIGZAG for digits: Series of transverse incisions at 90-degree angles with 5mm offset from digit midline. Apex of each zigzag centered over flexion crease but NOT crossing perpendicularly (prevents scar contracture and wound breakdown). Each limb of zigzag should be 10-15mm in length. Design allows extensile exposure while maintaining flap perfusion (base wider than tip). TRANSVERSE INCISIONS in palm: Parallel to distal palmar crease and thenar crease. Multiple transverse incisions preferred over single longitudinal (avoids scar contracture). Z-PLASTIES: Plan for contracted areas - transpose flaps to lengthen skin in line of contracture. 60-degree angle Z-plasty provides 75 percent length gain. McHSH TECHNIQUE option: Leave transverse PALM incisions OPEN (not sutured) - heals by secondary intention over 3-4 weeks with low infection rate and excellent outcomes. NEVER straight longitudinal incisions in palm or digits (unacceptable scar contracture risk). Make skin incisions with 15-blade scalpel through skin only (not into subcutaneous tissue - preserve subdermal plexus).

Step 4: Skin Flap Elevation

Elevate skin flaps carefully using fine scissors (tenotomy or iris scissors) and Adson forceps with teeth. Dissect in plane JUST SUPERFICIAL to diseased fascia - preserve subcutaneous fat and vascular plexus on undersurface of skin. Diseased cord is often ADHERENT to overlying skin, especially in severe long-standing disease. If skin BLANCHES (ischemic) or is very THIN (less than 2mm), plan to EXCISE that segment and perform full-thickness skin graft rather than risk flap necrosis. Use spreading technique with scissors to develop correct plane between skin and fascia. Create flaps with adequate blood supply: base must be WIDER than tip (minimum 1.5:1 ratio), preserve longitudinal vessels running in subcutaneous tissue parallel to digit, handle skin gently with forceps (minimize crushing trauma). Identify normal from diseased tissue: diseased fascia is WHITE, GLISTENING, THICKENED, CORD-LIKE with loss of normal fascial translucency; normal fascia is THIN, TRANSLUCENT, wispy appearance.

Step 5: Identify and Protect Neurovascular Bundles - CRITICAL STEP

FIND THE NERVE FIRST before cutting any diseased cord - this is the MOST CRITICAL principle of Dupuytren's surgery. Start dissection on ULNAR side of digit or palm (typically easier exposure, less disease burden). Use loupe magnification (2.5-3.5x mandatory for this step). Look for neurovascular bundle in ABNORMAL position - ASSUME displacement by spiral cord. Normal NVB position: mid-lateral line of digit at junction of dorsal and palmar skin. Spiral cord displacement: NVB moved CENTRALLY and VOLARLY by up to 1cm. Begin identification in proximal palm where anatomy is more normal, then trace distally. Use MICROSURGICAL technique: gentle spreading with fine tenotomy scissors, blunt dissection only around NVB, no sharp dissection near NVB until definitely identified. Digital nerve appears as PALE YELLOW cord with longitudinal striations, slightly glistening. Confirm by gentle palpation (nerve has characteristic firm but slightly compressible texture different from diseased fascia). Once identified, place VESSEL LOOP around NVB for protection and gentle retraction during cord excision. Identify common digital nerve bifurcation at web space level - particularly vulnerable to injury. Repeat process for radial NVB of affected digit.

Step 6: Dissect Diseased Cord from Flexor Sheath

Once NVB identified and protected with vessel loops, dissect diseased palmar fascia and cords away from underlying structures. Flexor sheath lies immediately deep to diseased fascia in digits - appears as WHITE, GLISTENING, SMOOTH structure. In palm, identify flexor tendons deep to diseased pretendinous bands. Use BLUNT DISSECTION technique: spreading with tenotomy scissors between diseased cord and flexor sheath, develop plane with gentle spreading motions. Diseased cord may have FIBROUS ADHESIONS to sheath from chronic inflammation - these require careful sharp dissection to release while preserving sheath integrity. Once plane developed, use combination of blunt and sharp dissection to separate cord from sheath along entire length. Flexor sheath must be preserved completely - any violation leads to adhesions, triggering, stiffness. Identify flexor tendon pulleys: A1 pulley at MCP level may be thickened or contributing to contracture - consider release if causing triggering or limiting correction. However, PRESERVE A2 (proximal phalanx), A3 (PIP joint), A4 (middle phalanx) pulleys - critical for preventing bowstringing and maintaining mechanical efficiency.

Step 7: Segmental Fasciectomy - Excision of Diseased Cords

With neurovascular bundles identified and protected, and diseased fascia separated from underlying flexor sheath, proceed with SEGMENTAL excision of diseased cords. PROXIMAL extent: Dissect to proximal palm, identifying transition from diseased (white, thickened, cord-like) to normal fascia (thin, translucent, wispy) - preserve normal proximal fascia. DISTAL extent: Follow diseased cord distally to its insertion (may extend to middle phalanx or DIP level) - excise completely. LATERAL extent: Excise diseased lateral digital sheet if involved (component of spiral cord). Use SHARP DISSECTION to divide diseased cord at proximal and distal ends after ensuring NVB protected. Excise en bloc when possible, or in segments if safer. REGIONAL fasciectomy definition: Remove all DISEASED segments while preserving NORMAL fascia (versus RADICAL fasciectomy which removes all palmar fascia including normal tissue - higher morbidity, rarely indicated). Send specimen to pathology (usually not required but document excision). Ensure complete removal of all diseased, contracted tissue to minimize recurrence risk - inspect carefully for residual bands causing contracture.

Step 8: Release PIP Joint Contracture if Present

PIP joint contracture requires additional releases BEYOND fasciectomy - fascial excision alone is insufficient for severe PIP contracture. After fascial cord excision, gently attempt passive PIP extension - if significant residual contracture (greater than 20 degrees), proceed with sequential releases. CHECK-REIN LIGAMENTS (accessory collateral ligaments): Release from volar plate insertion - these ligaments run from proximal phalanx to volar plate and become contracted, preventing PIP extension. Identify on both radial and ulnar sides of PIP joint. Divide sharply from volar plate origin (distal) while protecting collateral ligaments (dorsal). VOLAR PLATE: If contracted and preventing extension, perform PROXIMAL release from proximal phalanx origin - preserve distal insertion to middle phalanx (prevents swan neck deformity). Can score or make transverse releases in contracted volar plate. A3 PULLEY: Preservation preferred, but can release if severe PIP contracture persists after check-rein and volar plate release. INTRINSIC TIGHTNESS: Test with Bunnell test (PIP flexion easier with MCP extended versus flexed) - if positive and limiting PIP extension, consider intrinsic release at MCP level. CAPSULOTOMY: Rarely needed - only for severe longstanding contracture with capsular fibrosis. MANIPULATION: NEVER forcefully manipulate PIP joint to gain extension - high risk for proximal phalanx fracture, especially in elderly patients with osteoporosis. Use gentle progressive passive extension only after soft tissue releases.

Step 9: Release Natatory Ligament and Web Space Contracture

Web space contracture from natatory cord limits finger abduction and causes progressive narrowing of web (web creep). Identify natatory ligament at distal palm level, spanning commissure between adjacent digits. Natatory cord is diseased natatory ligament - thickened, contracted, cord-like. Protect common digital nerve BIFURCATION (particularly vulnerable during web space dissection - single injury affects two adjacent digits). Divide natatory ligament COMPLETELY - sharp transverse division at both proximal and distal attachments. Excise diseased natatory cord. Release superficial transverse metacarpal ligament if contributing to web contracture. After release, web space should allow normal finger abduction (can spread fingers apart). Address skin deficiency in web: plan Z-PLASTY to lengthen web skin and prevent recurrence. Four-flap Z-plasty or V-Y advancement techniques effective. Complete web release essential - inadequate release leads to web creep recurrence (progressive narrowing over time), limited abduction, functional impairment for grasp and wide objects.

Step 10: Assess Correction and Address Skin Deficiency

After complete fasciectomy and soft tissue releases, release tourniquet and assess hemostasis. Achieve meticulous hemostasis with bipolar electrocautery (low settings near neurovascular structures). Assess passive digital extension - should achieve near-full extension (0-10 degrees residual acceptable for MCP, 10-20 degrees for PIP depending on preoperative severity). Assess SKIN DEFICIENCY: attempt to approximate wound edges without tension - if cannot close easily, DO NOT force closure under tension. Skin deficiency occurs in 10-20 percent of cases. Management options: 1) Z-PLASTY: Transpose local flaps to lengthen skin in line of contracture - 60-degree angle Z-plasty provides 75 percent length gain. Multiple small Z-plasties can be used. 2) FULL-THICKNESS SKIN GRAFT (FTSG): For defects greater than 2cm after cord excision. Donor sites: hypothenar eminence (best color match, minimal donor morbidity), medial arm, groin (larger grafts available), volar wrist crease. Harvest FTSG with 15-blade, remove all subcutaneous fat, create template of defect, secure graft with 5-0 chromic interrupted sutures, apply tie-over bolster dressing. 3) McASH OPEN PALM TECHNIQUE: Leave transverse PALM wounds open (not sutured), heal by secondary intention over 3-4 weeks. Advantages: accommodates skin deficiency, near-zero hematoma rate, low infection, good outcomes. NOT suitable for digital wounds (must close digits to prevent scar contracture).

Step 11: Wound Closure and Dressing Application

Close skin incisions with 4-0 or 5-0 nylon interrupted sutures (monofilament preferred - less infection risk, easier removal). For Bruner zigzag incisions: suture APEX first to align flaps correctly, then close limbs of zigzag side-to-side. Avoid excessive tension on sutures (skin edge ischemia). If full-thickness skin graft placed: secure with 5-0 chromic interrupted sutures around periphery (6-8 sutures), then create TIE-OVER BOLSTER dressing over graft. Bolster technique: leave long tails on chromic sutures, place non-adherent gauze over graft, place cotton ball or gauze roll on top, tie chromic suture tails over bolster to create even pressure (prevents hematoma and shear). Bolster remains in place 5-7 days. If McCash open palm used: pack open palm wounds with non-adherent dressing (Xeroform or Adaptic), cover with gauze. Apply bulky DRESSING: fluffed gauze around digits and hand, wrap with Kerlix or Kling gauze, apply EXTENSION SPLINT. Splint position: wrist 30 degrees extension, MCP joints 0 degrees (neutral), PIP and DIP joints 0 degrees (full extension achievable). Splint fabricated from plaster or thermoplastic, extends from fingertips to proximal forearm on VOLAR surface. Splint purpose: maintain correction during early healing, prevent immediate re-contracture from wound contracture forces.

Step 12: Assess Neurovascular Status Before Leaving Operating Room

MANDATORY final step before leaving operating room. Release tourniquet and wait 5 minutes for reperfusion. Assess EACH affected digit systematically: 1) CAPILLARY REFILL: Compress fingertip nail bed and release - should pink up in less than 2 seconds. Delayed capillary refill (greater than 3 seconds) indicates arterial insufficiency. 2) COLOR: Digit should be pink - pale indicates arterial insufficiency, blue/purple indicates venous congestion. 3) TEMPERATURE: Palpate digit - should be warm. Cool indicates vascular compromise. 4) SENSORY: Test two-point discrimination on radial and ulnar sides of digit - compare to preoperative baseline documented in chart. Test light touch with fingertip. Patient should have intact sensation (may have paresthesias from anesthetic or retraction - document). 5) MOTOR: If WALANT anesthesia, can test active flexion. 6) ALLEN'S TEST: If concern for radial or ulnar artery injury during palm dissection. Document all findings in operative note. If ANY concern for neurovascular injury: re-explore immediately while still in operating room - early recognition and repair critical for outcome.

Day 0-2: Immediate Postoperative

• Bulky dressing with extension splint remains in place
• Elevate hand above heart level (reduce edema and hematoma risk)
• Ice therapy: 20 minutes on, 20 minutes off while awake (reduce pain and swelling)
• Pain control: regional block for first 12-24 hours, then oral analgesics (acetaminophen, NSAIDs, short-term opioids if needed)
• Neurovascular checks every 2 hours for first 24 hours (nursing protocol)
• Watch for warning signs: increasing pain (compartment syndrome, hematoma), numbness (nerve injury, compression), color change (vascular compromise)

Day 3-5: Early Motion Phase

• First dressing change and wound assessment
• Begin ACTIVE ROM exercises with hand therapist
• Splint removed for therapy sessions (3-4 times daily, 15-20 minutes each)
• Exercises: gentle composite flexion, isolated PIP and DIP flexion, full active extension, tendon gliding exercises
• Replace splint between therapy sessions and continuously at night
• Edema control: elevation, compression glove, retrograde massage
• If McCash open palm: begin daily dressing changes with non-adherent gauze

Day 10-14: Suture Removal

• Remove nylon sutures from closed incisions
• If skin graft: remove tie-over bolster at day 5-7, assess graft take (should be pink and adherent)
• Continue active ROM exercises, increase frequency to 6-8 times daily
• Begin scar massage with vitamin E cream or silicone gel (prevents hypertrophic scar)
• Continue splinting between exercises and all night

Week 2-6: Progressive Motion

• Progressive ROM: increase flexion and extension range
• Edema control: compression glove, Coban wrapping, retrograde massage
• Scar management: massage, silicone gel sheeting, pressure garment
• Continue extension splinting between therapy and night
• Assess for complications: CRPS (pain, swelling, color changes, temperature changes, sudomotor dysfunction), infection, stiffness
• If McCash open palm: wounds should be 75-90 percent healed by week 4

Week 6-12: Strengthening Phase

• Begin gentle strengthening exercises: therapy putty, graded grippers, functional activities
• Progressive resistance exercises
• Work simulation for return to employment
• Continue night splinting (critical - continue for 3-6 months total)
• Expect 80-90 percent of final motion achieved by 12 weeks

Month 3-6: Maturation Phase

• Continue strengthening and functional activities
• Night splinting continues through 6 months (compliance critical for preventing recurrence)
• Scar maturation (scars soften and fade over 12-18 months)
• Full recovery typically 6 months (return to all activities including heavy labor)

Expected Outcomes

• MCP contracture: 80-90 percent correction (excellent)
• PIP contracture: 50-70 percent correction (guarded, especially if severe)
• Grip strength: recover to 80-90 percent of contralateral hand by 6 months
• Return to work: light duty 6-12 weeks, manual labor 12-16 weeks
• Patient satisfaction: 75-85 percent overall (higher for MCP disease, lower for PIP disease)

Recurrence Counseling

• Recurrence risk: 20-50 percent at 5 years (median 3-5 years)
• Higher with Dupuytren's diathesis (young age, bilateral, family history, ectopic disease)
• Regular follow-up to monitor for recurrence
• Repeat surgery possible but higher nerve injury risk (10-15 percent in revision surgery)

References

1. Becker GW, Davis TR. The outcome of surgical treatments for primary Dupuytren's disease - a systematic review. J Hand Surg Eur Vol. 2010;35(8):623-626. Level II evidence - Systematic review comparing fasciectomy techniques, regional fasciectomy best balance of recurrence versus morbidity.

2. Dias JJ, Braybrooke J. Dupuytren's contracture: an audit of the outcomes of surgery. J Hand Surg Br. 2006;31(5):514-521. Level III evidence - Large case series demonstrating MCP correction 80-90 percent versus PIP correction 50-70 percent, worse outcomes with severe PIP contracture.

3. Ullah AS, Dias JJ, Bhowal B. Does a 'firebreak' full-thickness skin graft prevent recurrence after surgery for Dupuytren's contracture?: a prospective trial of operated hands. J Bone Joint Surg Br. 2009;91(3):374-378. Level I evidence - RCT showing dermofasciectomy (skin graft) reduces recurrence to 5-10 percent versus 20-40 percent with fasciectomy alone.

4. Townley WA, Baker R, Sheppard N, Grobbelaar AO. Dupuytren's contracture unfolded. BMJ. 2006;332(7538):397-400. Level V evidence - Expert review of Dupuytren's disease pathophysiology, anatomy of spiral cord and neurovascular bundle displacement, and surgical principles.

5. McFarlane RM. Patterns of the diseased fascia in the fingers in Dupuytren's contracture. Displacement of the neurovascular bundle. Plast Reconstr Surg. 1974;54(1):31-44. Classic paper - Describes spiral cord anatomy and mechanism of neurovascular bundle displacement (centrally and volarly up to 1cm), fundamental to understanding nerve injury risk.

6. McCash CR. The open palm technique in Dupuytren's contracture. Br J Plast Surg. 1964;17:271-280. Classic technique paper - Original description of leaving transverse palm wounds open to heal by secondary intention, demonstrating low hematoma rate, low infection, and good long-term outcomes.

7. Tonkin MA, Burke FD, Varian JP. Dupuytren's contracture: a comparative study of fasciectomy and dermofasciectomy in one hundred patients. J Hand Surg Br. 1984;9(2):156-162. Level III evidence - Comparative study showing dermofasciectomy recurrence 5 percent versus regional fasciectomy 20 percent at 5 years, but higher morbidity.

8. Rodrigues JN, Becker GW, Ball C, et al. Surgery for Dupuytren's contracture of the fingers. Cochrane Database Syst Rev. 2015;(12):CD010143. Level I evidence - Cochrane systematic review of surgical techniques, confirms fasciectomy superior to needle aponeurotomy for contracture correction and recurrence.

9. Citron N, Messina JC. The use of skeletal traction in the treatment of severe primary Dupuytren's disease. J Bone Joint Surg Br. 1998;80(1):126-129. Level IV evidence - Case series demonstrating external fixation and gradual correction as alternative for severe PIP contracture, outcomes comparable to aggressive releases.

10. Bulstrode NW, Jemec B, Smith PJ. The complications of Dupuytren's contracture surgery. J Hand Surg Am. 2005;30(5):1021-1025. Level III evidence - Large series documenting complication rates: nerve injury 3-5 percent (spiral cord 8-10 percent), skin flap necrosis 2-5 percent, hematoma 5-10 percent, CRPS 5-10 percent, recurrence 20-50 percent at 5 years.