Proper preoperative evaluation of associated problems (carpal tunnel syndrome [CTS], triggers, abductor band)
Early referral to therapy; proper wound care, and edema management
No-tension orthosis for the first 3 postoperative weeks
Gentle exercise technique to protect against wound and neurovascular tension
No suture removal before 2.5 weeks after surgery; 24-hour paper tape for an additional 3 to 4 weeks
Early identification of problems related to infection, sympathetic flare, or CTS
Progression to static or dynamic extension orthosis at 3 weeks after surgery
Attention to stretch for the intrinsic muscles, oblique retinacular ligament (ORL), and facilitation of the flexor digitorum profundus (FDP) tendon
No repetitive gripping exercise or forceful passive motion
Extension orthosis at night for 4 to 6 months
The purpose of this chapter is to examine postoperative rehabilitation techniques following surgical intervention for Dupuytren’s contracture (DC), with particular focus on improved functional outcomes and diminished postoperative complications. The reader who is interested in a more comprehensive review of the subject can follow links in the bibliography for more in-depth study. This chapter will emphasize the author’s preferred techniques.
Clinical experience teaches that some complications following Dupuytren’s fasciectomy may be attributed in part to aggressive management of the tissues by the therapist or patient with exercise and orthotic use; late referral to therapy, short-term follow-up, or undiagnosed pre-existing CTS or triggering digits. The rational, clinical research, and experience for this observation are defined in a previous paper and in the online appendix.
Dupuytren’s disease (DD) is a proliferative and progressive fibroplasia affecting the palmar fascia that can lead to flexion contracture in the metacarpophalangeal (MCP) and the proximal interphalangeal (PIP) joints, causing functional disability. The pathologic findings vary with the stage of the disease, progressing from early cellular nodules to dense fibrous cords.
This disease has been studied extensively since being described by Dupuytren in 1834 in terms of anatomy, etiology, genetics, pathophysiology, associated ailments, , demographics, surgical technique, and functional outcomes.
Nonoperative treatment for DC including enzymatic fasciotomy, skeletal traction and use of progressive mechanical tension orthoses, radiation, dimethyl sulfoxide, vitamin E, allopurinol, ultrasound therapy, steroid injection, interferon, and orthotic use have been studied and are summarized elsewhere. Most conservative interventions demonstrate only limited short-term improvement, but some of the newer procedures, including collagenase injection (enzymatic fasciotomy) with manipulation, and needle fasciotomy, have demonstrated promising results and gained popularity due to limited complication rate and quicker recovery. Long-term results for these interventions are not yet available.
Although DC is now better understood, with much new research on biochemical and cellular aspects, the true cause of the disease continues to be unknown, and little data is available about the response of these cells to various agonists such as mechanical stress.
Although techniques for surgical intervention and nonoperative treatment for DC are well described and reviewed in the literature, , , reference to postoperative therapy is, for the most part, inadequate and anecdotal, without much evidence other than clinical observation. Au-Yong and associates recently surveyed 141 hand surgeons regarding practice patterns for surgical and postoperative decision making in the treatment of DC. Questions regarding practice patterns and results of their survey addressed clinical decision making with regard to surgery, but revealed little information regarding postoperative management other than referral to therapy and time in orthoses with no details given on orthoses design with reference to joint angles or to actual therapeutic regimens.
Literature review produces few studies to support therapeutic interventions and conflicting support about the benefit, or lack of benefit for these interventions. As of this writing, no matches were found for evidence-based medicine or randomized controlled studies for physical agents or exercise protocols following surgical intervention for DC. Postoperative orthotic use as a therapeutic intervention also has little definition. Clinical experience and literature review show that postoperative orthotic use among hand surgeons and therapists varies significantly from relaxed extension, aggressive extension, tension relieved, to no tension. The antitension regimen for orthotic use and exercise described by the author is the only study that attempts to objectively correlate the effect of postoperative mechanical stress to complications of inflammation, sympathetic flare, hypertrophic scar, and functional range of motion (ROM). Currently, a multicenter, randomized, controlled trial is underway to determine the effectiveness of postoperative orthotic positions and duration of use.
The Value of Preoperative Therapy
There is a limited role for therapy post-operatively in DC. A single presurgery visit with the therapist is valuable for the patient because the therapist can support the surgeon’s interview by reiterating the postoperative sequelae, time frames for rehabilitation, and the need for prolonged night orthotic use, a well as help define realistic expectations for outcomes. Such a visit also benefits the physician because the therapist can assist with documentation of preoperative ROM; sensibility for each digital nerve; function of the flexor digitorum profundus (FDP), oblique retinacular ligament (ORL); degree of intrinsic tightness; documentation of abductor digit minimi band; screen for carpal tunnel syndrome (CTS) and triggering digits; and document the patient’s functional self-assessment with standardized outcome measures. , Early troubleshooting, especially with a screen for CTS, digital triggers, and the presence of an abductor band, can help prevent postoperative complications.
Several investigators have had success with preoperative continuous traction techniques to improve joint extension, but these devices have not gained popularity among surgeons, do have some complications, and the patient still requires fasciectomy. The author has a small series of patients ( n = 9) (referred by Paul Dell, MD, Shands Teaching Hospital, Gainesville, Florida) that have been treated preoperatively for 3 weeks with serial finger casting ( Fig. 23-1 , online) to improve proximal interphalangeal (PIP) joint extension by applying a low load continuously to connective tissues about the joint and to the Dupuytren’s fascia. The distal interphalangeal joint (DIP) is left free to stretch the ORL and to activate the FDP. This requires two serial cast changes per week, with exercise each session to work the PIP joint into extension, and to focus on activating the FDP and stretch for the ORL. On average, about 25 to 40 degrees of PIP extension are gained before surgical release with serial casting, and improvements are noted for FDP function and stretch to the ORL, but the study is ongoing. It has not been established if this technique shortens rehabilitation time or improves final results, but the referring physician feels that the serial casting simplifies the release and may help to improve final results. As these patients are usually in the age group for Medicare insurance, the issue about limited visits is a concern to therapists in free-standing rehabilitation units, so presurgical treatment should be kept to a minimum.
Postoperative Management: Author’s Preferred Technique
Postoperative complications, including infection, flap necrosis, white finger, nerve damage, sympathetic flare, hypertrophic scar, scar contracture from a poorly designed incision, joint stiffness, recurrence, and disease extension, have been well documented. We can anticipate that patients with more than two involved digits, radial disease, PIP flexion contracture greater than 45 to 60 degrees, and a ruddy type complexion (a clinical observation) can be expected to produce more postoperative complications. Rehabilitation protocols, as they relate to postoperative complications, have received limited attention in the literature, but may be a significant variable.
The goals of postoperative management are to foster uneventful wound healing by protecting wound fluids, preventing infection, minimizing adverse mechanical influences, and controlling the collagen maturation process. Basic wound-healing principles should be respected to regain joint motion and soft tissue extensibility without contributing to inflammation. Stressful exercise can compromise corner flaps and skin grafts, encourage the development of hypertrophic scar, and may contribute to sympathetic flare from aggressive stretch to the neurovascular bundles.
It is not uncommon for therapy protocols to include aggressive use of extension orthoses in early wound-healing phases and aggressive manual therapy, which, experience teaches, contributes to inflammation and postoperative complications noted earlier. A better approach is for the therapist to think in terms of tissue nutrition instead of ROM. Tension to the neurovascular bundles and cutaneous repair should be avoided. The rationale for this “no-tension” technique is that applied tension to digital vessel and nerve may contribute to local hypoxia and inflammation. Tissue anoxia may contribute to free-radical release and adverse cellular response, as well as hypertrophic scar formation in the lines of tension.
Postoperative Care—Weeks One and Two
In the author’s clinical setting, patients are treated 24 hours after surgery. Patients are always treated while they are supine the first postoperative visit to prevent a vasovagal episode and to decrease anxiety. Initial wound care includes drain removal (if present), wound cleansing with sterile water, cool compresses to reduce edema, and sterile dressing changes. Wounds are treated with mupirocin (Bactroban) topical antibiotic and contact layers (Adaptic if the skin is macerated, Xeroform if it is not). Digital wounds are dressed with -inch tube gauze with enough dressing (2 × 2-inch sterile gauze pads) to absorb any bleeding, and then a single layer of 2-inch self-adherent wrap (Coban) to control edema for the digital wounds. Dressing to maintain humidity speeds epithelialization, prevents dressing adherence, and avoids painful dressing changes. The benefits and science for moist wound healing are reviewed elsewhere. The patient is fitted with a dorsal blocking type orthosis with the wrist positioned at neutral, MCP joints at 35 to 45 degrees of flexion, and the interphalangeal (IP) joints in relaxed extension ( Fig. 23-2A ). The thumb is positioned in mild abduction if the first web was operated. Only the operated digits are included ( Fig. 23-2B , online).
Patients are instructed verbally as well as given written notations concerning hand elevation and sleeping techniques and the need to keep the dressing dry and to avoid exercise the first few days, both for the operated hand and for their usual total body exercise regimen. Shoulder management includes proper positioning for elevation and sleeping that prevent shoulder impingement positions, and exercises that keep the shoulder joint capsule extensible. The upper trapezius and levator scapulae muscles may develop trigger points from improper positions of elevation, posturing, and disuse associated with postoperative sequelae. Cervical stretches for bilateral upper trapezius and the levator scapulae, and myofascial massage for both, address these symptoms.
Patients usually return to the clinic again in 48 hours for wound care and to begin gentle exercise. Wound care advances to a mild (Dove or Ivory pump) soap and water wash at the sink supervised by the therapist, with the predescribed dressing application. Patients are instructed to exercise with gentle composite digital flexion, within the confines of the orthosis, and to avoid stress to the corner flaps of the incisions ( Fig. 23-2C ). Exercise to end range of digital extension and flexion are avoided. Many patients, especially the retired male who is used to an aggressive approach in business and sports, tend to overwork and to edit the therapist’s instructions. These patients need a firm approach and written instruction with clear definition.
Postoperative Care—Week Two to Three
Week two to three includes exercise advancement to increased angles of flexion and extension with respect to wound healing. The IP joints are best worked by the therapist with gentle manual, axial traction to prevent cartilage abutment. Aggressive passive exercise only compromises the wound and increases joint inflammation, so it should be avoided. If wound healing is progressing satisfactorily, digital orthoses including the proximal phalanx (P1), middle phalanx (P2), and distal phalanx (P3) applied to the volar aspect of the digit can be applied four or five times per day with 1-inch Transpore tape ( Fig. 23-3 ). The tape applies light extension forces to the PIP joints. Functional electrical stimulation (FES) can be utilized as a type of muscular reeducation and to facilitate flexor and extensor tendon glide. FES to improve digital extension should be applied both with the MCP joints manually blocked in flexion to transmit forces to the PIP level by week three, and for composite extension. Wound care progresses to lighter dressings, continued single-layer Coban wraps, and suture removal when the wound edges demonstrate adequate tensile strength. Early suture removal with wound dehiscence results in wider and often hypertrophic scar. , A frequent scenario for wound complication is suture removal at 10 days or less after surgery by the nurse or physician assistant before the surgeon sees the patient, with resulting wound dehiscence. Suture removal at 16 to 17 days, or even longer if the patient is diabetic and the corner flaps are not stable, helps to prevent the formation of painful or hypertrophic scar. Attention to basic wound-healing principles minimizes complications.
Scar management progresses to 24-hour paper taping once sutures are removed to minimize skin tension . One-inch Micropore paper surgical tape placed longitudinally along incision lines, or lines of tension, especially where the incision crosses a joint, minimizes scar/skin tension and thus the development of hypertrophic scar. , Patients are instructed to change the paper tape when they shower. The scar should be massaged prior to showering with gentle transverse motions, and then following showering the scar and volar tissues are cleansed of any oils with isopropyl alcohol. For the paper tape to adhere, the skin must be free of oil and completely dry. Silicone gel sheeting is applied to the scar at night if the scar is hypersensitive or hypertrophic. The silicone is worn inside the night extension orthosis. Molded elastomer can be used in combination with a night orthosis for larger palmar areas, however, paper tape is less expensive and actually gets equal or better results than the more expensive gels or elastomers. ,
The antitension orthosis continues until week three, and then daytime use is discontinued. The dorsal orthosis is remolded to a volar hand-based extension device with straps placed strategically over the MCP and PIP joints to maintain or improve joint extension and is worn at night ( Fig. 23-4A ). If carpal tunnel symptoms are exhibited, the orthosis should include the wrist at 2 degrees flexion and 3 degrees ulnar deviation. The patient should be cautioned about repetitive composite fisting, which elevates pressures at the A1 pulley , and in the carpal tunnel. Controlled stress to the tendon and ligament systems progresses with gradual increase in composite extension as the neurovascular bundles begin to accommodate increased tension. Isolated flexor tendon gliding, including hook, and full fist are recommended at least five times per day for short intervals (15–20 repetitions per exercise). The patient is instructed in intrinsic stretch, isolated DIP motions with the PIP joints at 0 degrees to facilitate ORL stretch. A dynamic extension orthotic can be utilized (applied week 2–4) for the more difficult cases where MCP and PIP joint extension are not satisfactory and when the application of multiple digital static orthotics are difficult for the patient to apply independently ( Fig. 23-4B ). Digital orthotics can be placed inside the traction loops intermittently to provide a composite extension stretch. Therapy aides such as putty and hand grippers are not utilized because they increase pressure in the carpal tunnel and at the A1 pulley region, , and, if overdone, cause flexor tendon inflammation. Again, overly aggressive exercise should be cautioned against.
Postoperative Care—Weeks Four to Six
By week four the wounds are epithelialized, edema should be under control, and motion should, for the most part, be reestablished. Therapy can be discontinued or decreased to one or two times per week unless the patient has not progressed satisfactorily. Exercise progression continues with a light strengthening program. This should include isometric strengthening with a 2-inch dowel instead of exercises such as putty squeezing, which bring the fingers into the palm and if utilized repetitively, as mentioned earlier, increase pressure in the carpal tunnel and A1 pulley region. Exercise with the home program should continue to include stretch to the intrinsic muscles and ORL; FDP gliding relative to the FDS; strengthening and facilitation of the zone III and IV extensor tendon gliding; and overall strengthening for the wrist extensors and rotator cuff musculature for return to sports or heavier activity. Gloves with a gel pad in the palmar region decrease pressure for sports activity that requires grip. Composite digital extension orthoses are best continued for 3 to 6 months, with intermittent use of a daytime digital extension orthosis or dynamic extension orthosis as deemed necessary. Patients benefit from brief periodic visits to the therapist to ensure compliance with long-term orthotic use. In the author’s clinic, quick courtesy rechecks are done at no charge and serve to emphasize the need for prolonged orthotic use and as intervention if joint extension is lost due to noncompliance.
Patients referred following needle fasciotomy for Dupuytren’s bands typically do not require much intervention. The same principles should apply for a gradual increase in extension orthotic use without an aggressive approach for either exercise or the orthosis, and the use of padded gloves for activities, such as racket sports, golf, or gardening, that apply stress to the palmar aspect of the hand. In the author’s experience, these patients expect to see the therapist for only one or two visits and plan to return to normal activities immediately .
Intervention for Complication
The therapist should intervene quickly for complications related to infection, inflammation, edema, or sympathetic flare by sending the patient to the physician for assessment and medication change, and by altering therapeutic protocols to address the specific problem. Sympathetic flare related to the development of carpal tunnel symptoms that were either missed preoperatively or develop postoperatively may require carpal tunnel release (CTR). In the author’s experience, patients followed immediately postoperatively following CTR or trigger release associated with Dupuytren’s surgery, or as an intervention for postoperative complications, progress well with careful management of the involved tissues.
Inflammatory problems can be addressed with changes in exercise patterns, orthotic positions, and the use of high-voltage galvanic stimulation and cold applications. Edema can be addressed with Isotoner gloves, Coban wraps, fluid-flushing exercises, and elevation. Painful or hypertrophic scar can be treated with ultrasound or iontophoresis with dexamethasone sodium phosphate, paper taping and silicone, desensitization, and massage. Physical agents used as therapeutic interventions for edema, pain, and inflammation are reviewed elsewhere in this text, but as mentioned previously, no evidence exists other than clinical experience to support these interventions with DC.
Triggering digits can be addressed by altering forces at the A1 pulley with a hand-based MCP extension orthosis or use of a profundus orthosis only (P2, P3 dorsal orthotic) during the daytime and by limiting repetitive gripping ( Fig. 23-5 ).
Difficult PIP flexion contractures can be treated with serial casting (see Fig. 23-1 ) for several weeks, or intermittent digital orthotic use taped precisely over the PIP joint with 1-inch Transpore tape (see Fig. 23-3 ). Dynamic digital-based orthosis are recommended by some authors, but tend to migrate and are difficult to fit for the small finger. If PIP joint flexion or intrinsic stretch is an issue, a volar wrist control with lumbrical block (MCPs at 0 degrees) can be applied with flexion vectors for the PIP to stretch the intrinsics and to improve PIP joint flexion ( Fig. 23-6 ). Composite flexion issues are often more related to intrinsic tightness than limitations with joints or the extensor system. Improving excursion of the intrinsic muscles facilitates composite digital flexion.
A home exercise program is critical to maintaining motion gained in surgery and therapy. Patients need to be required to reproduce exercises without cue as well as proper orthotic application. Typically, most patients do not exercise with precise exercise position, repetition, or force application, and most become lax once they are discharged from formal therapy. Written exercise programs, questioning in therapy, and quick rechecks after discharge help to ensure compliance with home programs.
Rationale and Clinical Experience for the No-Tension Technique
The effect of mechanical stress on Dupuytren’s palmar fascia and cellularity, occlusion of capillary endothelium, , tissue anoxia and oxygen free radicals, and growth factor release has been studied. In an attempt to understand the pathogenesis of this condition, studies have defined the role of the myofibroblast in force transmission to the extracellular collagen and matrix in DD. Research into therapeutic regimens have examined the effect of continuous stress on the collagen fibers of Dupuytren’s tissue applied prior to surgery, with results indicating that preoperative stress on these tissues can trigger the release of enzymes that weaken collagen.
These studies, which address the biochemical and biomechanical response of these tissues to mechanical agonists, may raise questions regarding some popular rehabilitation techniques that apply tension to vessel, nerve, and incision lines with orthotic use and exercise techniques that often apply stress beyond the physiologic limits of accommodation in this operated tissue. Tissue nutrition in the early postoperative phase following Dupuytren’s fasciectomy has not received enough attention by therapists, and mechanical stress applied by the therapist or patient may be a critical variable in the complication rate and outcomes that has been overlooked.
The author and associates hypothesized in a previous study that orthotic use on the operated digits under tension following fasciectomy may contribute to negative alterations in neurovascular function, altered tissue nutrition, and facilitate hypertrophy of scar in lines of tension; and that stressful exercise technique that contributes to edema or inflammation may also contribute to localized hypoxia. This theory finds some support in basic science studies that look at cellular response to mechanical stress and tissue anoxia. *
* See Appendix online for more in-depth review.
Clinical Experience: Materials
The authors first reported clinical experience is defined elsewhere in a review of 268 patients treated exclusively by the author over a 17-year period, comparing the results of patients treated with tension applied to the operated digits immediately after Dupuytren’s fasciectomy versus those treated with the antitension technique described earlier ( Table 23-1 , online). The patients were operated on by 49 surgeons, with no controls on surgical technique.
|No Tension Applied||Tension Applied|
|Mean age (SD)||69.33 (6.78)||67.15 (8.91)|
The first group tension applied (TA), n = 103, consisted of 76 male and 27 female patients with a mean age of 67.15 (±8.91) and average number of operated digits 1.96 (±0.71). These cases were evaluated retrospectively from 1983 to 1993, and prospectively from 1993 to 1999. The primary author treated the cases from 1983 to 1993 with an extension orthosis immediately postoperatively as standard accepted protocol. Cases included in this group from 1993 to 1999 were those sent to the primary author at 2 weeks or greater postoperatively wearing physician-applied orthoses. A limited number ( n = 13) were seen as follow-up after being treated first at other therapy units.
The second group was the no tension applied group (NTA), n =165, which consisted of 128 male and 37 female patients with a mean age of 69.33 (±6.78) and an average number of operated digits 1.6 (±0.7). These patients were all studied prospectively from 1993 to 1999, and treated with the no-tension protocol following the clinical observation by the primary investigator that following Dupuytren’s fasciectomy a number of patients treated with tension applied developed flare.
Treatment Protocols: Methods
Patients in the TA cohort received an orthosis with tension applied to the operated palmar and digital regions with efforts to obtain extension immediately postoperatively from 20 to 0 degrees at the MCP and to neutral PIP joint extension ( Fig. 23-7 ). Extension orthoses were worn intermittently during the day (with self-exercise sessions prescribed four to six times per day), and during the night. Exercise efforts were directed to regaining digital extension immediately postoperatively according to standard postoperative protocol. No attempt was made to apply aggressive tension for the sake of this study, and the technique of applying tension was not utilized by the primary author after 1993.