In some patients the extent of the Dupuytren's tissue can be excessive, instead of a simple cord or nodule, there can be a diffuse matting of fibrous tissue. This can involve the overlying skin and is a particular feature in recurrences and also when the disease affects the little finger especially in younger people.

If surgery is required then a simple operation may not be adequate to control the disease and a more extensive procedure may be necessary. I refer to this procedure as a resurfacing job. It involves removing the skin and underlying fibrous tissue, whilst carefully preserving the nerves and blood vessels and then applying a full thickness skin graft. I usually take this from the inside of the upper forearm. This operation takes much longer than the simple procedures and the risks and potential complications are higher. The outcome is significantly improved in non-smokers.

After surgery.

On discharge from hospital an appointment will be made to see a hand therapist approximately one week post surgery. At home keep your hand elevated on pillows or in a sling for the first week to reduce excessive swelling and bleeding. This elevation is absolutely critical to the outcome as it reduces the swelling and improves the chances of graft healing (see General Advice). Remember to regularly move the fingers which are not contained in the dressings/bandages, and to move your shoulder and elbow out of the sling to prevent other joint stiffness and complications.

The hand must be kept clean and dry to prevent infection and avoid softening any plaster of paris splints under the bandaging. A plastic bag may be placed over the dressings and fastened securely for showering (aqua-shields may be purchased from some chemists for this purpose).

Wound care

The dressings will be taken down by your therapist at your first appointment approximately one week post surgery, and both the donor site and hand wound checked. The appearance of the wound may be a surprise to you, but do not worry they always look similar to the picture.

The therapist will then apply a light dressing and fashion a removable thermoplastic splint to hold your finger(s) out straight. This must be worn at all times, except when you are asked to perform your exercises.

Approximately two weeks post surgery your therapist or consultant will cut the end of the stitches at the donor site (the internal stitch is dissolvable). The dressing can then be left off and you will be able to get your graft site wet.

The healing of the new graft site in your hand will depend on your natural healing ability. However it may take up to three to four weeks before fully healed. The redness in the graft will gradually fade until it assumes a more normal skin colour. The wound must be kept dry until fully healed and will be regularly checked and redressed by your consultant or therapist.

Gentle exercises will begin one to two weeks post surgery to regain range of movement in your hand. Please be guided by your therapist as excessive movement may reduce the healing of the wound, while not enough movement leaves you at risk of complications.

When the wound is fully healed, your therapist will teach you to massage your wound with E45 to soften the scar tissue combined with stretches to extend your fingers. This is essential to your rehabilitation. Gradually you will be weaned out of your splint during the day time and you will be able to return to light activities. Depending on your recovery you may be required to wear your splint at night for 6 months and occasionally up to one year.

Exercises

Remove your splint and begin the following exercises only when instructed by your therapist.

1. Using your other hand fold all your fingers into a fist, then try and keep them there on their own. Repeat five times every two hours.

2. Actively make a fist. Repeat five times every two hours.

3. With our hand resting on a table, palm facing upwards, straighten out your fingers so that the nails touch the table, then relax. Repeat five times every two hours.

4. Spread your fingers as far apart as possible, then close. Repeat five times every two hours.

5. With the other hand stretch the affected finger(s) as advised by the therapist. Repeat five times every two hours.