Research using large national datasets has confirmed that surgery for the common hand disorder Dupuytren’s disease is safe and effective. When surgery needs to be repeated, however, there are higher risks of serious complications such as finger amputation.
In Dupuytren’s disease, the tissue beneath the skin of the palm becomes thickened; this often does not limit use of the hand. But one in three will experience Dupuytren’s contracture, which means their fingers bend inwards, and they need surgery to straighten them.
This study compared three different types of surgery for Dupuytren’s disease. It looked at the risk of complications, including the need for repeat operations, after each. The researchers hope their findings will better inform surgeons and patients of the risks and benefits of the different types of surgery.
What’s the issue?
Dupuytren’s disease is an incurable hand disorder. Many people with the disease see lumpy, scar-like tissue in their palm. This may not limit use of the hand, but some people experience pain, itching, burning, or aching.
Up to one in five men over 60 years, and women over 80 years, have Dupuytren’s. The exact cause is unknown, but it runs in families, and gene variants play a major role in the development of Dupuytren’s. It is also linked in some people to smoking, alcohol consumption and diabetes.
For one in three people with the condition, their fingers gradually bend inwards towards the palm. Eventually, they cannot be straightened again. This means people are unable to use their hands for everyday tasks. Surgery is currently the only reliable treatment.
There are three well-established types of surgery:
- Percutaneous needle fasciotomy - a needle cuts across the band of tissue which is forcing the fingers to bend in.
- Limited fasciectomy - all the diseased tissue is removed. This is the most common type of surgery.
- Dermofasciectomy - all of the diseased tissue and the overlying skin is removed, and the skin replaced by a skin graft.
Limited research suggests that almost one in four (23%) people have complications after surgery. Complications in the hand (local) include infections, injury to nerves and tendons, and finger amputation. Complications affecting other areas of the body (systemic) are related to having anaesthetic, including stroke, heart attack, urinary tract infection, kidney damage or failure, and death.
The researchers wanted to establish the risk of serious complications following surgery for Dupuytren’s disease. They also looked at how often repeated surgeries took place and what their outcomes were.
The team studied adults who had surgery for Dupuytren’s disease in NHS hospitals in England between 2007 and 2017. During this ten-year period, 121,488 adults had 158,119 operations. They searched these records to see how people fared in the first three months after surgery, and again, 10 years later.
Overall, surgery for Dupuytren’s disease in the NHS is effective and safe with low complication rates. Within 90 days of surgery:
- less than one in 100 (0.8%) patients experienced serious systemic complications
- one in 100 (1.2%) of patients experienced serious local complications
- surgery performed under general or regional anaesthesia carried an increased risk of serious systemic complications such as heart attacks, respiratory infections, and kidney damage, but the overall rate was low; local anaesthesia was safer.
Ten years later, many patients had needed repeat surgery:
- one in three (34%) after percutaneous needle fasciotomy
- one in five (20%) after limited fasciectomy
- one in five (18%) after dermofasciectomy (higher than shown in previous research).
Repeat surgery carried the risk that surgeons cutting through scar tissue might damage blood vessels, which could lead to the finger dying. Around one in twenty (5%) people having a second operation after dermofasciectomy had an amputation within three months.
Other factors had an impact. People living in more deprived areas were less likely to have surgery, and repeat surgery, but they had more complications. Older people, and those with a higher number of other health conditions, were also more likely to have complications. Men had a higher risk of infections after surgery than women, but were less likely to need a second operation.
Why is this important?
This research provides information on complication and reoperation rates after the different types of surgery for Dupuytren’s disease.
Surgeons could use these findings to help their patients decide on the best type of surgery for them. For example, percutaneous needle fasciotomy is keyhole (minimally invasive) surgery. It has a lower risk of serious complications, but carries a higher risk of re-operation.
For high-risk patients, such as those who are older or have other conditions, surgeons could consider using local anaesthesia (rather than regional or general anaesthesia).
The findings show that primary surgery and re-operations for Dupuytren’s disease are less common in areas of high deprivation. This suggests that people living in areas of high deprivation may have difficulty accessing medical services or may be dying younger than people in less deprived areas. Policymakers need to ensure that all people in need of surgery can access the help they need.
There should be further research into whether more widespread use of local anaesthesia during Dupuytren’s disease surgery reduces even further the rare complications such as heart attacks and pulmonary embolism.
Linking primary and secondary care datasets would produce a more complete picture of local complication rates, such as infection. It would enable detailed analysis of the costs of surgery. Combining patient outcomes with cost-effectiveness would help inform policy around the three types of surgery.
Some of the researchers are investigating the causes of Dupuytren’s disease. They hope it will lead to new, non-surgical treatments. The team is also examining the safety and effectiveness of hand trauma surgery in the UK with the aim of improving standards of care.
You may be interested to read
The full paper: Alser O, and others. Serious complications and risk of re-operation after Dupuytren’s disease surgery: a population-based cohort study of 121,488 patients in England. Scientific Reports. 2020;10:16520.
The International Dupuytren Society; an organisation dedicated to supporting patients and promoting research, education and global cooperation to find a cure for Dupuytren Disease and related conditions.
This study was supported by the Oxford NIHR Biomedical Research Centre and an NIHR Clinician Scientist grant.