Treatment

Dupuytren's

 DUPUYTREN'S DISEASE: FREQUENTLY ASKED QUESTIONS
AND LINKS TO PUBLISHED STUDIES: FAQS & FACTS

These pages include answers to frequently asked questions regarding Dupuytren's disease. There is quite a bit known about Dupuytren's, but because we don't yet have all of the pieces of the puzzle, the bits that we do know don't all fit tidily together. There are also a fair number of undocumented urban legends. This page only includes information which has been investigated and published in recognized medical journals - the stuff that doctors read. For verification and more information, this page links to source material at the National Library of Medicine. Browse around! There's quite a bit here to consider.

- Treatment -

The two "Catch-22s" of Dupuytren's, or why there's no perfect treatment:
  1. 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.
  2. 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 wounding 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.
What medical treatments have been shown to help? 10050246

What are other treatment options? 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 6529287. Final outcome after surgery is worse in patients who have an earlier age of onset, severe PIP joint involvement, and small finger involvement 1284016. Surgery is usually recommended when MCP contractures progress to 30 degrees, when PIP contractures develop 1769986, or the patient develops a positive "table top test" 7060997, 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:

Table Top Tests:

Normal

For NA

For Surgery
  • Procedures:
  • Closure techniques
    • Open palm 10050248, 9746881, 8856539 , 7847092, 1937183, 10050248, or modified open palm 8567134, 1564282, 1769994. In this method, the fascia is divided or removed using transverse incisions, which are left open to heal by themselves. 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 6693744, although contradictory reports also exist 3944435. As with other techniques, results following open palm technique are best in the treatment of isolated MCP contractures 6480188.
  • Complementary Procedures
    • 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 6884845. Stretching exercises other than these are not recommended.
    • Massage: As noted above, vigorous stretching or traction is probably wrong for Dupuytren's. However, there is anecdotal evidence that direct pressure massage may help soften nodules and firm areas related to Dupuytren's. One technique for direct presure 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, as shown here:
    • 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 room is usually better than the final result 12601600, 12073190, 9303892.
        • Percutaneous 3794477
        • Open Not indicated routinely 10050249, may require extensive release 9336654. Therapy is usually indicated after surgery for PIP contracture 10050247. Small finger is most likely to require release, and results are not a favorable as ring finger releases 9303892. Loss of flexion is common after open release 9303892. Wound healing problems are also common 9303892, 8596787. The effectiveness of PIP joint capsule release is debatable 8596787. On the average, there is less than 50% improvement in the final range of motion following PIP contracture 1430959.
    • PIP Arthroplasty (joint replacement) an uncommonly used alternative to PIP fusion or amputation 3908601.
    • 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 12531666
    • Excision of the palmaris longus tendon has been reported to reduce recurrence 3740784.
    • Osteotomy or PIP fusion for recurrent severe PIP flexion contractures with palmar soft tissue fibrosis 1769996, 3559089, 4078465.
    • Amputation for recurrent severe contractures with hygiene or overall health problems 8308443, 3449003, 4078465.
  • Radiotherapy 11757183, 11233838, 11172962, 10803052, 10758324, 9082583, 8960518, 3975949, controversial: 8359061 , 2071079
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.
  • For the 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 3968392. 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.
Dupuytren's Procedure Results Calculator
Enter numerical information below, and the diagram to the left will demonstrate PIP and MCP angles before and estimated improvement after Dupuytren's procedures. Calculations are based on similar early results with both open fasciectomy and needle aponeurotomy. Neither open surgery nor needle release is a perfect solution, and partial improvement is the expectation with more severe contractures. This page calculates a general estimate - actual results may be better or worse than this.
What finger? Index Middle Ring Small
What is the PIP contracture of that finger? degrees
What is the MCP contracture of that finger? degrees
How many digits (fingers and thumb) are involved on that hand?

Complications of treatment  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 7152373. Flare reaction after surgery may be more common in women 1769992. Surgery may actually aggravate the process, and patients may be worse off after surgery than they were before 1769994 . Complication rates following surgery have been reported in the range of 17% to 41% 8994009, 9303892, 9214276, 10050251, 3944435. Complications are nearly twice as common following repeat surgery than for primary surgery 9214276.

  • Post Surgical
    • Early
      • Hematoma
      • Swelling 11291357
      • Infection
      • Flare - more common in women 3693825.
      • RSD 7% following open, 1564282, more likely in women 2229974 0% following needle aponeurotomy. Incidence may be less in severe contractures when surgery is performed in two stages 4007639.
      • Wound dehiscence
    • Later
      • Pseudoaneurysm
      • Inclusion cysts
      • Finger stiffness / loss of flexion is common 3944435, especially in women 3693825.
      • Recurrence
        • The majority of operated patients eventually have recurrent contractures 11252689, 10697321. Recurrence within the first few years after surgery has been reported in the range of 27% to 34% 1564282 1960492. Recurrence rates five years or more after surgery are higher, ranging from 40% to 74% 1564282 1481713, 1564282 1284017, 1284016, 3181828, 3233038 . 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 3233038.
        • The small finger is the worst for recurrence 11496607, 1284016 , possibly because of the unique anatomy of tissues on the outer border of the small finger 2338307 .
        • Recurrence requiring repeat procedure after needle aponeurotomy is at least 24% 11496606, and has been reported as 23% following open fasciectomy 1564282.,
        • With diffuse skin involvement, dermofasciectomy is more successful fasciectomy in preventing recurrence 10697321, 1284018, 3309018,and earlier surgery is recommended 1284017 .
        • Surgery for recurrent contracture due to Dupuytren's disease may be successful only if it includes excision and skin flap rather than skin graft 10722821.
        • The relative risk of recurrence can be predicted by microscopic evaluation of tissue removed at surgery 2754197. Highly cellular lesions have higher rates of recurrence than do hypocellular lesions, a finding which may be demonstrated on MRI 8456670.

 

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