Enter #:

What's This?

Dupuytren's Clinic Product Recommendations Patient Education Patient Education Patient Education Patient Education
Treatment Options

     

Because the cause and recurrence of Dupuytren’s are not fully understood there is no perfect treatment.  Several medical and procedure treatments have been tried in order to cure the disease. Although some have been shown to be more effective than others, there is one fact that remains clear – at this time there is no cure for the disease and all forms of treatment have a high liklihood of recurrence.


The following is a summary of the current treatment options for Dupuytren’s Contracture:

MEDICAL TREATMENT


Biologically, Dupuytren's is just like the shrinking and scar formation normally activated as part of the body's normal wound healing process.  So, any medicine strong enough to stop this process would logically have to also damage the body's basic ability to heal. A medical treatment will be developed, but it will have to be nontraditional.

Injections


Cortisone injection has a specific action on Dupuytren's nodules. It helps shrink and soften nodules and may slow the progression of the disease but does not relieve contracture.
Collagenase Injection
"Enzymatic fasciotomy" - high recurrence rate

Medications

While all of these have shown some promise in basic science research, there are no good studies that show effective use in patients.

  • Allopurinol
  • Colchicine
  • Tamoxifen
  • Saporin (from Saponaria officinalis)
  • 5-fluorouracil
  • Interferon (IFN-alpha2b)
  • Gamma-interferon
  • Calcium channel blockers (e.g... nifedipine, verapamil)
  • Vascular endothelial growth factor (VEGF) antagonists




SURGICAL TREATMENT

The palm of the hand affected by Dupuytren's behaves as though it is trying to shrink and heal an open skin wound that isn't there. When surgery leaves skin wounds, because the hand has Dupuytren's, the normal reaction to the wound can be greatly exaggerated:  swelling, stiffness, tenderness, difficulty using the hand, and this reaction can drag on for much longer than it would without Dupuytren's. The reaction to open surgery can result in permanent complications even if surgery is technically perfect.


Summary of Surgical procedures:

  • Closed cord rupture (traumatic rupture - Not recommended! )
  • Fasciotomy – cutting the cord but not removing the diseased tissue
  • Leaving the fascia rather than excising it does not increase the chance of recurrence. Active disease regresses after fasciotomy releases the cord tension.
  • Fasciotomy with external fixation to treat PIP contracture
  • Percutaneous (needle aponeurotomy is a type of percutaneous fasciotomy), works best for isolated MCP contracture.
  • Fasciectomy – removal of diseased tissue
  • Z-plasty without fasciectomy has been recommeded for single ray involvement.
  • Fasciotomy and ("firebreak") skin graft.
  • Fasciectomy
  • Segmental (AKA segmental aponeurectomy)
  • Partial (AKA Skoog, selective or partial aponeurectomy) appears to give as good results as total aponeurectomy, with fewer complications.
  • Complete Fasciectomy (aka Total Fasciectomy or Radical Aponeurotomy) has been reported to have lower recurrence
  • Dermofasciectomy and skin graft: Lower recurrence rate compared to fasciectomy reported, although debate. Indicated for small finger PIP joint contractures, in patients with Dupuytren's diathesis, recurrence or diffuse skin involvement. Recurrence may occur beneath a skin graft.


Surgical Decision Making

There is a general tendency for surgeons to recommend minimal surgery (e.g... fasciotomy) for early disease, fasciectomy for established disease and more aggressive surgery (e.g... dermofasciectomy) for advanced or recurrent disease.

Final outcome after surgery is worse in patients who have an earlier age of onset, severe PIP joint involvement, and small finger involvement. Surgery is usually recommended when MCP contractures progress to 30 degrees, when PIP contractures develop, or the patient develops a positive "table top test", as shown here. Needle aponeurotomy may be performed when the fingers can't be lifted from a tabletop; open surgery is reserved for contractures which prevent the palm from fully contacting a flat surface:

Closure techniques

If an open surgery is performed, the skin will need to be stitched together at closure. Various recommendations have been made regarding closure.

Open palm, or modified open palm (McCash Procedure) In this method, the fascia is divided or removed using transverse incisions, which are left open to close on their own like a scraped knee. The wound may be surprisingly large, but on the average heals in 3 to 5 weeks. The technique minimizes the chances of infection, hematoma, or skin necrosis, and has been reported to have lower rates of complications and recurrence, although contradictory reports also exist. As with other techniques, results following open palm technique are best in the treatment of isolated MCP contractures.

Simple closure Various types of incisions and closure with suture. None have been shown to be superior:

  • Zplasty
  • V-Y
Skin graft (plantar)

Skin flap


OTHER TREATMENTS



Preoperative Stretching programs are different than simply trying to stretch the fingers straight. In the short term, stretching may straighten the fingers, but the long run, stretching alone probably worsens the contracture. Stretching exercises other than these are not recommended.

Therapy

Hand Therapy for stretching or massage is not effective to prevent or reverse the disease process
Hand Therapy after surgery, particularly after PIP release is shown to be helpful.

Splinting

Splinting static progressive, without tension after surgery, dynamic extension splinting probably not helpful, passive motion splinting not helpful.
 

Intermittent Pneumatic Soft-Tissue Distraction


External fixation

Effective at relieving PIP contractures but recurrence rate is high.

Massage

As noted above, vigorous stretching or traction is not recommended. However, there is anecdotal evidence that direct pressure massage may help soften nodules and firm areas related to Dupuytren's. One technique for direct pressure massage is to roll a cylinder (such as a 1/2" to 1" diameter wooden dowel) between the palm and a flat surface such as a tabletop.

PIP Joint release

Sometimes needed because the joint can remain bent even after releasing or removing all of the abnormal Dupuytren's tissue. Improvement in the operating.

Percutaneous
Open - Not indicated routinely, may require extensive release. Therapy is usually indicated after surgery for PIP contracture.  Small finger is most likely to require release, and results are not as favorable as ring finger releases. Loss of flexion is common after open release. Wound healing problems are also common. The effectiveness of PIP joint capsule release is debatable.  On the average, there is less than 50% improvement in the final range of motion following PIP contracture.

PIP Arthroplasty (joint replacement)

an uncommonly used alternative to PIP fusion or amputation.

Tendon Lengthening

In patients with severe contracture, shortened muscle/tendon structures may prevent correction. In some patients, the tightest tendons may be lengthened through a separate operation in the forearm, called an intramuscular tenotomy

Excision of the palmaris longus tendon

has been reported to reduce recurrence.

Osteotomy or PIP fusion for recurrent severe PIP flexion contractures

with palmar soft tissue fibrosis.

Amputation

A possible option for more severe disease.

 

HOW EFFECTIVE IS SURGERY?

Metacarpophalangeal (MCP) joint contractures involving only one finger can almost always be corrected with surgery or needle aponeurotomy. However, when two or more adjacent MCP joints are contracted, the skin is usually contracted as well, and complete correction is less likely.


Proximal interphalangeal (PIP) joint contractures, the realistic expectation is improvement, not perfection. PIP contractures due to isolated cords in the fingers have been reported to improve an average of 50% after surgery. Straightening achieved in surgery is often patially lost during the healing phase (see recurrence). Use this calculator to estimate the final degree of proximal interphalangeal (PIP) joint bend after surgery. The math is based on the 1980 statistical analysis of Legge and McFarlane, based on the finger involved, the contractures of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of that finger, and the number of fingers involved. This is a statistical estimate, to give an idea of how tricky the problem is, not a guarantee of result, which may be better or worse than predicted. Similar outcomes can be expected for needle aponeurotomy (percutaneous fasciotomy) as for open surgery.

    

TREATMENT COMPLICATIONS


Postoperative complications include excessive inflammation, hematoma, ischemic skin necrosis, infection, granuloma formation, transient paresthesia, scar contracture, persistent proximal interphalangeal (PIP) flexion contracture, distal interphalangeal (DIP) hyperextension deformity, joint stiffness, poor flexion and grip strength, pain, and reflex sympathetic dystrophy (RSD). Comparing surgical incisions, skin necrosis, hematoma and pain problems are more likely with zig-zag exposures, while delayed healing and nerve injuries were reported more often after transverse incisions. Flare reaction after surgery may be more common in women. Surgery may actually aggravate the process, and patients may be worse off after surgery than they were before. Complication rates following surgery have been reported in the range of 17% to 41%,. Complications are nearly twice as common following repeat surgery than for primary surgery.


Surgical

  • Digital nerve injury
  • Vascular injury
  • Skin flap "button holes"


Post Surgical

Early

  • Hematoma
  • Swelling
  • Infection
  • Flare - more common in wome.
  • RSD 7% following open procedure, (more likely in women).  0% following needle aponeurotomy. Incidence may be less in severe contractures when surgery is performed in two stages.
  • Wound dehiscence


Later
         

  • Pseudoaneurysm
  • Inclusion cysts
  • Keloid (rare)
  • Finger stiffness / loss of flexion is common, especially in women.
  • Recurrence

 

FACTS ABOUT RECURRENCE

  • The majority of operated patients eventually have recurrent contractures. Recurrence within the first few years after surgery has been reported in the range of 27% to 34% Recurrence rates five years or more after surgery are higher, ranging from 40% to 74%. Recurrence is much more likely when surgery has been required before the age of 50, when associated with Ledderhose or Peyronie's disease, when the preoperative contracture is severe, or when accompanied by diabetes, alcoholism or epilepsy.
  • The small finger is the worst for recurrence, possibly because of the unique anatomy of tissues on the outer border of the small finger.

  • Recurrence requiring repeat procedure after needle aponeurotomy is at least 24%, and has been reported as 23% following open fasciectomy.

  • With diffuse skin involvement, dermofasciectomy is more successful fasciectomy in preventing recurrence, and earlier surgery is recommended.

  • Surgery for recurrent contracture due to Dupuytren's disease may be successful only if it includes excision and skin flap rather than skin graft.

  • The relative risk of recurrence can be predicted by microscopic evaluation of tissue removed at surgery. Highly cellular lesions have higher rates of recurrence than do hypocellular lesions, a finding which may be demonstrated on MRI.

 

Last updated 10.10.08

© Grabow Hand to Shoulder Center.