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Dupytrens Open Fasciectomy

Preoperative Patient Care

A

Intermediate Evaluation and Management

1

Obtain focused history and performs focused exam

  • check the range of motion

2

Prescribes and manages nonoperative treatment

  • attempts trial of physical therapy

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Provides postoperative management and rehabilitation

  • 1 week postoperative visit
  • remove splint
  • diagnose and management of early complications
  • continue range of motion exercises
  • remove all dressings by 4 weeks
B

Advanced Evaluation and Management

1

Provides post-op management and rehabilitation

  • gradually increase range of motion
C

Preoperative H & P

1

Perform basic medical and orthopaedic history and physical

  • check neurovascular status
  • check range of motion

2

Perform operative consent

  • describe complications of surgery including
  • wound complications
  • neurovascular injury
  • stiffness

Operative Techniques

E

Preoperative Plan

1

Execute surgical walkthrough

  • describe the steps of the procedure verbally prior to the start of the case

2

Description of potential complications and steps to avoid them

F

Room Preparation

1

Surgical Instrumentation

  • loupe magnification

2

Room setup and Equipment

  • standard operating table
  • hand table

3

Patient Positioning

  • patient placed in the supine position with hand on hand table
  • place tourniquet high on the affected extremity
G

Palmar Incision

1

Mark and make incision

  • make a transverse incision in the middle of the palm
  • extend the incision to the finger when needed
  • extended incision is through a zig-zag brunner incision
H

Deep Dissection

1

Dissect through subcutaneous tissue

  • undermine the skin flaps

2

Identify the diseased tissue

  • carry the dissection proximally until a transition between normal and diseased fascia is identified
I

Excision of Diseased Tissue

1

Isolate the neurovascular structure

  • isolate and protect the neurovascular structures from the diseased tissue and protect
  • dissect the neuoravascular structures from the diseased cords, retract them and protect them during the entire procedure

2

Release the diseased tissue

  • release the diseased tissue proximally and extend the dissection distally

3

Isolate the diseased tissue

  • transect the pretendinous cord proximally and follow the cord distally, dividing all connections to the adjacent normal tissue
  • if present, include the diseased Septa of Legueu and Juvara and a natatory cord from the diseased NL
  • if the diseased tissue extends into the finger, follow the digital cord into the finger
  • the digital cord must be dissected carefully because of the close proximity to the neurovascular bundle
  • identify and release the distal insertion of the digital cord

4

Excise the dissected tissue

J

Wound Closure

1

Irrigation and hemostasis

  • copiously irrigate the wound

2

Closure of the palmar incision

  • keep the transverse incision open to heal by secondary intention

3

Closure of the extensions of the incisions

  • close any extensions of the original incision into the fingers

4

Dressings and immediate immobilization

  • apply nonadherent gauze to the wound and immobilize the hand in a forearm based splint with the fingers in extension

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive postoperative orders

  • pain management
  • outpatient PT
  • start active range of motion exercises 48 to 72 hours postop
  • keep in nocturnal extension splint at night

2

Discharges patient appropriately

  • write for pain meds
  • schedule follow up appointment in 1 week
R

Complex Patient Care

1

Comprehensive pre-op planning/alternatives.

2

Modify and adjust post-op plan as needed

 

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