Evidence
Alert

Surgery for hand disorder Dupuytren’s disease is effective, but repeat operations come with higher risks

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.

What’s new?

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. 

What’s next?

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.

This work is part of a larger project to analyse surgery for a range of hand conditions, including arthritis and carpal tunnel syndrome

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 EnglandScientific Reports. 2020;10:16520. 

More information about Dupuytren’s disease from the British Society for Surgery of the Hand

The British Dupuytren’s Society; a patient organisation that provides information and support to people affected by Dupuytren’s Disease, Ledderhose Disease and related conditions

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

Disclaimers

NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Funding: This study was supported by the Oxford NIHR Biomedical Research Centre and an NIHR Clinician Scientist grant. 

Conflicts of Interest: One author has received funding and other support from various pharmaceutical companies, unrelated to this work. 

Commentaries

Study author

The main message of our study is that surgery for Dupuytren’s disease as practiced in the NHS is safe.

We’ve known for a long time that repeat surgery is more difficult than primary surgery. This is because operating through scar tissue increases the risk of damage to nerves and blood vessels. But we found that repeating surgery after dermofasciectomy carried a surprisingly high risk of damaging the blood supply. Despite the relatively high risk, this is a rare event. As such, many surgeons would see few cases like this during their career and would find it difficult to estimate the risk for patients. Using large national datasets, as we did in this study, can help surgeons and patients understand the risks. 

Surgery for many hand conditions is being increasingly rationed in the NHS, with something of a postcode lottery. The work we’re doing underlines the fact that this is not equitable and shouldn’t be restricted.

Dominic Furness, Professor of Plastic and Reconstructive Surgery, University of Oxford  

Support group

The problem with a so-called “postcode lottery” in accessing elective treatment is long-standing. The British Dupuytren’s Society would welcome national guidelines to give all patients a fair chance to get the treatment they and their surgeon think best suits their presentation and circumstances – and at the time it is needed.

I have heard of patients being denied needle fasciotomy because their clinical commissioning group did not consider it value for money. They had to postpone treatment as they could not afford a long time off work for the recovery. I have also heard of people being denied surgery because of a high BMI. And if surgery can be done under local anaesthetic, these patients could go back to exercising and working a lot sooner.

At the moment many patients are being told referral is only possible at 30-45 degree contracture (which is when results of surgery are optimal), and by the time they have seen a consultant and are top of the list for surgery, it can be 12-18 months later. By then, the contracture is a lot worse and straightening the finger may not be possible.

By bringing these findings to the attention of our healthcare providers, we hope there will be a positive change.

Anne Schurer, Chairperson, British Dupuytren’s Society