Hand Surgery Sydney North Shore

• A layer of tissue under the skin and above the tendons, nerves and vessels in the hand is the palmar aponeurosis. This layer is white in colour and has natural thickenings in certain parts of the palm and fingers (called bands).
• In Dupuytren’s disease these natural bands thicken abnormally causing development of thick bands of tissue called cords. As cords thicken they cause the fingers to abnormally bend at certain joints, not allowing them to straighten.
• As cords develop, they can cause severe bending of fingers, with the ring finger being most commonly affected, followed by the little, middle, index fingers and thumb.
• As this fascial tissue thickens in certain areas it can form hard nodules.

• Under the skin especially in the areas around the bases of the fingers, the abnormal tissue encases the nerves pulling them closer to the middle of the finger, as well as close to the skin.
• In some patients the disease is so severe and rapidly progressing that it:
  • Occurs at an early age (in 20s-30s)
  • Affect multiple fingers on both hands
  • Causes knuckle pads (called Garrod’s pads) to develop
  • Affects the feet (Lederhosen’s disease)
  • Affects the penis in men (Peyronie’s disease)

• Treatment for Dupuytren’s disease is not curative, and is directed at removing the cords that cause functional impairment. By definition, the disease continues to occur, and cords can reform.
• Duputren’s disease should therefore be treated in patients who have:
  • Functional impairment with work or daily activities
  • Their finger is bent by more than 30 degrees at the first knuckle i.e. At the junction of the finger and the palm (the MCP joint)
  • Their finger is bent by any degree at the first finger joint (the PIP joint)
• Treatment is not indicated for patients who have
  • No functional impairment
  • Involvement of the palm only
  • Involvement of the finger with only a slight bend at the first knuckle (MCP joint)
  • Isolated nodules

• Dupuytren’s disease can be treated non surgically or through surgery

Non-surgical treatment (Collagenase – Clostridium Histolyticum, Xiaflex)

• This is an enzyme that dissolves certain types of Collagen found in the abnormal cords
• This medication is prepared and injected directly into the cord in an office setting
• One vial is generally used per cord
• The patient then returns 24048 hours later and the cord is ruptured by manual manoeuvres after a nerve block.
• This does cause pain, bruising, swelling and requires a splint.
• The main downsides of this treatment include
  • Cost
  • Not entirely pain free
  • Carries a 30-40 per cent risk of recurrence
  • There is a risk of tendon rupture and allergic reaction to the medication

• Performed under General anaesthetic in a hospital setting
• Depending on extent of disease and number of fingers the surgery can take 45-60minutes per finger.
• Patients may stay only the day in hospital or overnight
• Medicare/Health fund rebate: Yes which covers all the hospital costs of surgery and part of the surgical and anaesthetic fee.

• Is performed under tourniquet control
• Longitudinal incisions are made on the finger
• The diseased fascia and cords are removed taking care to preserve the tendons, and especially the nerves which are often encased within the diseased tissue
• The aim of the procedure is to get the finger as straight as possible, and sometimes certain parts of the joints may need to be released as ligaments around the joints may shorten over time due to the abnormal position
• Closure is then performed often with Z plasties, and dressings are then applied as well as a back slab

• You may go home the same day or stay overnight
• You will be sent home with a sling and adequate pain relief, as well as some oral antibiotics.
• You will be referred to a hand therapist who will change your splint to a thermoplastic splint, and begin exercises shortly after the operation. You will be required to wear the splint for a short while during the day, and then for several weeks at night, in order to maintain the straight position of the finger.

• Generally excellent, although there is a period of wound healing, and hand therapy to achieve maximal recovery.

Every surgery carries risks, and therefore one must consider if risks outweigh the benefits for your own personal situation. If they do then the surgery may be well worth it. Dr Aggarwal will discuss the pros and cons of surgery with you during your consultation.

General Complications

• Risks of anaesthetic – there are general risks of going under an anaesthetic such as a mild stress on the heart and lungs, risk of reaction to anaesthetic drugs and risk of clotting in the legs. These risks are generally low in patients who are otherwise fit and healthy.
• Bleeding (1-2%) – any bleeding is controlled during surgery and really only arises from the skin incisions. Most stops with hand elevation and compression.
• Infection (<1%) – this is very rare. However you are given antibiotics during induction (when you are going to sleep), as well as a course of oral antibiotics after your surgery to keep this risk to a minimum.
• Poor Wound Healing (5%) – Occasionally the thin skin (created as a result of the fascia being excised directly under the skin) is slow to heal and this may require a period of dressings before complete wound closure is achieved. This can be slower if skin grafts are needed (patients with severe nodule formation or those with severe bending of the fingers), or in patients who are diabetic or actively smoking.

Specific Complications

• Change in sensation – The nerves of the finger may be traumatised during surgery as the cords are dissected free of the nerves that they may encase. As long as the nerves are preserved intact, sensation usually returns but can take months. There is however a risk of injury to the nerve, and if this occurs the nerve is repaired but it can then take longer for the sensation to return.
• Change in vascularity – Just as the nerves are at risk of injury in severe Dupuytren’s disease, so are the arteries located directly behind them. Furthermore in severely bent fingers the straightening of the finger itself can cause stretch and spasm of the vessels, enough that the finger can become white after surgery. If this occurs the finger is rewarmed and the vessels checked. In most cases the finger pinks up on rewarming and re-bending.
• Hypertrophic or poor scars – How one’s body behaves to scarring is individual and largely genetic. Some types of skin are more prone to hypertrophic or keloid scarring, and some individuals and families are more prone to this. We will routinely advise you on how to improve the quality of scars over time. You should also discuss any history of abnormal scarring with Dr Aggarwal preoperatively.

Do I need a referral for Dupuytren’s disease?

• Yes
• This allows you to claim a Medicare rebate of approximately $73 for the initial consultation, and to be eligible for rebates for surgery.

Where can I see Dr Aggarwal?

• You can see us at our main practice at Gordon, or at one of our other locations at Hornsby, Hunters Hill or Camperdown.
• Please scroll to the bottom of the page to find out more information about these locations.

Where will I have my operation?

• Any of the hospitals where Dr Aggarwal works – i.e. Sydney Adventist Hospital, SAN Day Surgery, or Hunters Hill Private hospital.

What can I do to prepare for surgery?

• Cease fish oil, and other supplements such as Ginkgo, Ginseng.
• Please discuss with Dr Aggarwal if you are on blood thinning medications as to when you should stop and recommence those.
• If you are smoking you need to cease this well in advance of surgery.

After surgery, will I need to wear a special garment?

• Yes you will be placed in a backslab immediately. This will be changed to a thermoplastic splint by a hand therapist after surgery, who will guide you as to how often you will need to wear it.

Will I be able to exercise after surgery?

• You should not do any exercise that raises your blood pressure for at least 72 hours after surgery
• Light exercise is generally allowable at 4 weeks
• Heavier exercise should be avoided for 6-8 weeks

Will I need special medications after surgery?

• Dr Aggarwal will provide you with the necessary scripts for antibiotics and pain relief.

Will I need further surgery?

• Not usually.

Can I travel in an airplane after surgery?

• Yes
• However we always encourage patients not to be away overseas shortly after having a procedure, so that we can closely follow your recovery and address any concerns that may arise.

When will I be able to swim after Dupuytren’s disease surgery?

• You may swim in a pool or beach after all the wounds have healed. In general this takes at least 2-3 weeks but it can sometimes be longer.

When will I be able to drive after Dupuytren’s disease surgery?

• No – it is illegal to drive with a splint and as long as this is required to be worn during the day you will not be able to drive. Once the splint is no longer required during the day, your wounds have healed, and your movement in your hand and fingers is good you will be able to resume driving. Your hand therapist will guide you with this.

Are there any alternatives to surgery?

• Non-surgical options for Dupuytren’s disease include Collagenase injection.

• The price for Dupuytren’s disease surgery depends on the number of fingers involved and severity of the condition.
• At Mode we follow the schedule of fees listed by the Australian Medical Association for this procedure.
• The cost of Collagenase is approximately $1200 per vial, and this is comparable to surgery.
• Please note that the above pricing does not include
  • Preoperative consultation fees – which are $250 for the initial consult and $125 for additional preoperative consultations