The first surgical patient is relatively straightforward, treated with regional fasciectomy and Z-plasties, showing that a good result can be obtained with this method. However, for severe recurrent contractures after soft tissue release, one may need to cover the large soft tissue wound with a flap or skin graft. One should even consider PIP fusion or, rarely, amputation. In this case, a 55-year-old man had recurrent flexion contracture of the right little finger after prior Dupuytren surgery. It is difficult to distinguish scar contracture from recurrent Dupuytren disease. He did not have any prior wound healing problems after the first surgery. After excision, the patient is left with a large soft tissue wound that was covered with a vascularized pedicle, heterodigital island flap taken from the adjacent ring finger, whose donor site then was subsequently treated with a full thickness skin graft. This subsequent functional outcome is demonstrated a year later in the bottom right. For recalcitrant contractures, consider a PIP joint fusion. In this next case, a 63-year-old female patient had two prior attempts to resolve her dysfunctional left small finger flexion contracture from Dupuytren disease. She had previously been very compliant with her post-operative therapy. She did not desire undergoing another very strenuous therapy, and the adjacent ring finger had also previously been released, so the large resulting soft tissue wound in the small finger was covered with a cross-finger flap from the dorsum of the ring finger. When the PIP joint was fused in a more functional position, she avoided an amputation and retained five digits with a functional hand. While radiation therapy as a primary treatment for Dupuytren contracture is controversial and lacks controlled studies, we have used it successfully as an adjunct to surgery for severe secondary procedures, as demonstrated in a 63-year-old male patient with severe residual contractures in the dominant right-hand ring and small fingers. Extensive surgical release was performed, and the wound covered with a split-thickness skin graft. With post-operative, low-dose irradiation was given over five successive treatments. His function is shown six months later and has remained durable until now, even five years later. Occasionally, one may choose more than one treatment modality on a given patient. So finally, in a case of severe primary Dupuytren disease, multiple treatment modalities were selected, choosing the best that each has to offer. This patient had severe index and thumb and first webspace contracture. The small finger was acutely flexed into the palm, and there was also more moderate involvement of the ring finger. There was skin maceration with excessive moisture collection in the distal palm at the base of the flexed small finger. We chose to achieve correction in stages. The first webspace, thumb, and index finger were released at the first stage. At this first stage, a needle aponeurotomy was done to at least get the small finger out of the palm and enable skin care. A dynamic external fixator using a digit widget from the biomechanics lab in Sacramento, California was used to resolve the small finger PIP joint contracture. Finally, surgical release of the ring and small fingers was successfully completed by regional fasciectomy and Z-plasties.

Dupuytren's contracture

surgical approaches

flap grafts

PIP fusion

radiation therapy