DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Severe Dupuytren disease, right hand, with flexion contracture, right small finger.
POSTOPERATIVE DIAGNOSES:
1. Severe Dupuytren disease, right hand, with flexion contracture, right small finger.
2. Boutonniere deformity, right small finger.
OPERATIONS PERFORMED:
1. Subtotal fasciectomy, right palm.
2. Subtotal fasciectomy, right small finger, with full-thickness skin graft harvested from the upper arm.
3. Right small finger proximal interphalangeal joint collateral ligament release.
SURGEON: John Doe, MD
ANESTHESIA: Axillary block.
COMPLICATIONS: None.
TOURNIQUET TIME: 100 minutes.
OPERATIVE FINDINGS: The patient developed a severe flexion contracture involving the right small finger due to Dupuytren disease. There was abundant Dupuytren fascia at the mid palm extending onto the palmar surface of the small finger all the way to the level of the distal interphalangeal joint. There was severe flexion contracture of the MCP joint and PIP joint, measuring 65 degrees at each level. There was also extension contracture of the distal interphalangeal joint consistent with boutonniere deformity. Subtotal fasciectomy and small finger proximal interphalangeal joint collateral ligament release was indicated.
DESCRIPTION OF OPERATION: Consent was signed by the patient for subtotal fasciectomy and interphalangeal joint collateral ligament release. He was taken to the operating room. Axillary block anesthetic was administered by the anesthesiologist. The right upper extremity was prepped and draped sterilely. A tourniquet was inflated on the upper arm following exsanguination of limb.
Brunner-type incisions were placed beginning at the level of mid palm extending distally onto the palmar surface of the small finger to the level of the distal joint flexion crease. Under loupe magnification, subcutaneous tissue was dissected to preserve full-thickness skin flaps. Beginning proximally, the skin was elevated off of the pretendinous cord. The cord was dissected and divided at the level of the mid palm.
The digital neurovascular bundles were exposed and dissected distally towards the distal palm crease. The Dupuytren fascia was divided at the level of the flexor tendon sheath and lateral gutters. The digital nerves were adherent to the Dupuytren cord, requiring careful neurolysis to dissect the nerves free and permit safe excision of the Dupuytren cord. Spiral and retrovascular cords were seen as the dissection was carried onto the digit. The digital neurovascular bundles were protected during this dissection.
The Dupuytren cord and diseased fascia was then excised and specimens sent to Pathology for analysis. The finger was then able to be extended fully at the MCP joint, but there was residual PIP joint flexion contracture. Therefore, collateral ligament release was needed to restore full extension of the PIP joint. The neurovascular bundles were retracted safely and the tendon sheath was incised at the level of the A3 pulley. The checkrein ligaments were divided. However, the flexion contracture remained.
The collateral ligaments were then divided radially and ulnarly, which then permitted full extension of the PIP joint. The distal joint showed residual extension contracture. The intrinsic tendons were then dissected free from the tendon sheath, to which they were adherent. This resulted in some improvement of passive flexion at the DIP joint. The skin flaps were inspected. The flaps adjacent to the MCP joint crease showed residual diseased fascia adherent to the dermis.
Therefore, considering this as well as the patient’s age and the severity of the condition, full-thickness skin grafting was thought to be warranted. The diseased fascia and overlying skin was excised. A full-thickness skin graft was harvested from the medial aspect of the upper arm in an elliptical fashion.
The donor site was irrigated and closed primarily using 4-0 chromic sutures and 5-0 nylon sutures. The skin graft was then placed over the skin defect at the base of the small finger. The tourniquet was deflated and circulation returned to the right hand. There was normal capillary refill in all digits, including the small finger.
Bleeding was controlled with direct pressure and hemostasis was achieved. The skin edges were reapproximated with 5-0 nylon sutures. The skin graft was sutured to the skin edges using running 4-0 chromic followed by moist cotton stent secured with 5-0 nylon sutures.
A sterile bulky gauze dressing was applied followed by forearm-based plaster splints, maintaining the fingers in slight flexion and protecting the skin graft. The circulation to the small finger remained intact with brisk capillary refill. Sterile gauze was applied to the skin graft donor site.
The patient was transferred to the recovery room in stable condition at the end of the subtotal fasciectomy and interphalangeal joint collateral ligament release. He tolerated the procedure well with no complications.
