5 Exposed Tendons
5.1 Patient History Leading to the Specific Problem
A 45-year-old man is seen in the outpatient clinic with an advanced stadium of Dupuytren’s disease of his fourth finger (▶Fig. 5.1). The contracture of the ring finger of the proximal interphalangeal (PIP) joint is greater than 90 degrees (Tubiana stage 3). Although he had been suffering since decades from this condition, he reported that during the last 12 months the contracture has progressed. The patient had no prior operations at this hand. He showed an aggressive type of Dupuytren’s contracture with a very thick central cord. The cord was directly attached to the skin, which made the operation challenging.
5.2 Anatomic Description of the Patient’s Current Status
The patient’s situation is the result of a very aggressive form of Dupuytren’s disease and his reluctance to see a hand surgeon. This case is more often seen in a recurrent disease. This condition makes the operation exceptionally complicated in terms of closing the defect after resection of the Dupuytren cord. The longer a patient with a Tubiana stage 2 or greater waits to see a surgeon, the more the skin is already retracted and the more complicated an operation. As a rule, the greater the ankle of the joint contracture, the less the skin available for closing the wound. Moreover, the older the patient, the thinner the skin and therefore the less tension tolerated by the skin during suture. One further aspect is the particular kind of Dupuytren’s disease. The increased expression of collagen type I/III fiber varies in every patient. If the fibers grow extensive induratively, the dissection of the subcutis can be very difficult and the risk of damaging the latter is inevitable. This type goes less often along with strong contractures such as found in our patient.
5.3 Recommended Solution to the Problem
One should first plan operations with all surgical risks and inform the patient about the necessity of all kinds of flap surgery. If the loss of skin is too large so that Z- and VY-plasties for coverage would have a high risk for complications, a full-thickness graft or a local skin flap is the next option. Another surgical option is the “open palm” technique by McCash. In this technique, an oval area open for secondary healing is left in the palm. If the cords make up more than half of the palm, the infection risk is too high. Usually for open palm treatments, daily dressings are mandatory and wound healing should be completed after 4 to 6 weeks. For this operation type, it is necessary that the patient is extremely compliant; otherwise, there is risk of a superinfection. We determined that in the above-described case, the arising defect is too large to apply McCash’s technique. Therefore, the choice for treatment was open fasciectomy with skin grafting (dermofasciectomy).
5.3.1 Recommended Solution to the Problem
• Anticipating complications due to severe skin infiltrations of Dupuytren’s disease.
• Operation planning (if necessary full-thickness skin transplantation, local flap surgery).
• Tell your patient to quit smoking 4 weeks prior to the operation and until wound healing is completed.
• Do an extensive patient education with all possible complications.
• Elevate the hand to decrease swelling. Edema can also cause pressure on the skin.
The patient is planned for an operation with an inpatient stay for at least two nights. Under plexus anesthesia or general anesthesia, the arm is prepped and an upper arm tourniquet is applied. Incision is made oval shaped all around the cord until half of the proximal phalanx (▶Fig. 5.2). The next step is complete dermofasciectomy. The cord is excised while sparing blood vessels and nerves. While preparing the cord, you have to make sure that you leave the paratenon intact. Then we plan the full-thickness skin graft. We take it from the palmar side of the forearm. Be aware of the fact that the graft shrinks and recoils. Therefore, always plan the size a bit bigger. Do not forget to incise your transplant to prevent seroma or hematoma between the graft and the wound bed. Nonadherent tie-over bolster dressings are ideal to improve adherence of the skin graft with the wound ground. Immobilization helps prevent sharing of the graft. The patient left the operation room with an extension splint.