Dupuytren Contracture Management Update

Dupuytren disease affects approximately four percent to six percent of the U.S. population. It is much more common in males than females, and prevalence increases with age. Myofibroblasts are central to the pathologic changes that occur with the disease, and the cords are thought to form in response to mechanical stress.

The condition was originally described in the 1600s, and treatment recommendations in the late 1700s–1800s included percutaneous and open fasciotomy. Over time, fasciectomy and radical fasciectomy became the treatments of choice; however, the latter fell out of favor due to increased morbidity and decreased effectiveness. This led to the development of minimally invasive techniques, including percutaneous needle fasciotomy and enzymatic fasciotomy.

Despite centuries of management, however, no universal guidelines have been accepted for treatment of Dupuytren contracture. In this article, we provide an overview of the current treatment options for the disease.


Dupuytren contracture of small finger proximal interphalangeal joint.
Courtesy of Stephanie Russo, MD, PhD, and C. Liam Dwyer, MD

Conservative treatment
Treatment of Dupuytren contracture must be individualized. The efficacy of non-operative treatments, such as physical therapy and splinting, is not well-described. While decreased contracture has been reported, conclusive evidence of efficacy is lacking. Low-demand patients may maintain an acceptable level of function without invasive treatment.

Needle aponeurotomy
This office-based procedure is indicated for palpable cords with sufficient skin coverage. The benefits of aponeurotomy include low cost, avoidance of anesthesia, and rapid recovery.

First, connections between the skin and the cord are disrupted, followed by repeated perforation of the cord. The involved joints are then extended to rupture the cord. Although significant gains may be achieved, at five years, a recurrence rate of 85 percent has been reported. Concomitant fat grafting has also been described, but its efficacy has not been conclusively demonstrated.

Collagenase clostridium histolyticum injection
The indications for collagenase injections are similar to those for needle aponeurotomy. Collagenase injection is contraindicated in patients with an allergy to the collagenase enzyme. Its safety is unknown during pregnancy, breastfeeding, and in patients who have a bleeding disorder or who take anticoagulants. Improvement in contractures crossing the metacarpophalangeal joint tends to be more consistent than those crossing the proximal interphalangeal joint.

Collagenase injections can be performed in the office. Patients return the following day for manipulation under local anesthesia. Manipulation may be delayed up to one week with similar outcomes. Two vials of collagenase may be utilized for two joints or two rays of the same hand in a single treatment session; however, higher complication rates have been reported. Recently, collagenase injections have also been utilized for treatment of nodules associated with Dupuytren disease.

Benefits of collagenase injection include short procedure and recovery times and avoidance of anesthesia. However, the considerable enzyme cost may be prohibitive for some patients. Additionally, although the complication rates following collagenase injection are higher than the frequency noted with surgical management, the complications tend to be less severe and are frequently self-limited.

Surgical management
Surgical management is appropriate for patients with complex or multijoint involvement, recurrent disease, and those who prefer surgery to office-based procedures.

Additionally, residual joint contractures, secondary pathologies, or other surgical conditions (e.g., carpal tunnel syndrome) may be addressed concurrently, if needed. Composite contractures (sum of the metacarpophalangeal and proximal interphalangeal joints) greater than 90 degrees and recurrent proximal interphalangeal joint contractures are often best addressed surgically.

Various surgical procedures, including open fasciotomy, limited fasciectomy and dermofasciectomy, have been described. Dermofasciectomy is typically reserved for patients with multiple, severe recurrences or high diathesis scores (risk factors for biologic severity of disease including dorsal nodules, bilateral palmer disease, family history, onset age younger than 50 years, male gender, first ray disease, multiple digits involved, and Ledderhose disease).

Postoperative splinting and therapy are common; however, active extension has been shown to be similar between patients who received postoperative night splinting combined with therapy and those who received therapy alone.

Although disease recurrence is generally lower than with needle aponeurotomy and collagenase injections, flare reactions may occur in approximately 10 percent of patients. Permanent stiffness occurs in half of those patients sustaining flare reactions. Utilizing tensionless postoperative immobilization may reduce the risk of flare reactions.

Severe proximal interphalangeal joint contractures (fixed contractures greater than 60 degrees) may be associated with secondary changes including extensor laxity, flexor tightness, and joint capsule contracture.

In these situations, staged procedures with preliminary skeletal extension torque followed by fasciectomy or dermofascietcomy achieve better outcomes than single-stage fasciectomies. Skeletal shortening procedures including proximal interphalangeal joint shortening arthrodesis, middle phalangectomy, or amputation may also be considered. Composite contractures greater than 135 degrees may limit surgical exposure or be complicated by skin maceration, and these cases may require a staged management approach. Boutonniere deformities may require concomitant distal interphalangeal joint arthrodesis. Finally, some patients have undergone cortical reorganization. This central nervous system adaptive mechanism mimics amputation and is marked by flexion of the involved digits during attempted finger straightening. These patients are unlikely to achieve satisfactory outcomes from procedures intended to restore digital function.

Conclusion
Patients with Dupuytren contracture have reported dissatisfaction with the education they have received regarding their available treatment options. Further, their treatment preferences vary. Ongoing research seeks to better understand the pathophysiology and identify new potential treatments for Dupuytren. Minimally invasive treatments, such as collagenase injections, offer low morbidity. They also lower recurrence rates when performed in patients with minimal arthrofibrosis. Traditionally, open surgery was indicated for contractures greater than 30 degrees. These minimally invasive procedures may be considered earlier and may be repeated with early contracture recurrence.

Recently, there has been a push toward standardization of treatment indications for Dupuytren contracture; however, management remains variable. Additionally, inconsistency in timing and measurements reported in outcomes studies limits the generalizability of findings. Treatment success may be defined as contracture correction to less than or equal to 5 degrees at 90 days following the procedure. Recurrence may be defined as greater than or equal to 20 degrees loss of post-procedure correction. The metacarpophalangeal and proximal interphalangeal joints should be assessed individually as proximal interphalangeal joints tend to demonstrate lower correction and higher recurrence rates.

Treatment recommendations for Dupuytren contracture are impacted by disease presentation and involvement, patient preference, and surgeon preference. To maximize patient satisfaction, surgeons should thoroughly discuss with patients the risks and benefits of each treatment option.

Stephanie Russo, MD, PhD, is an orthopaedic surgery resident at the University of Pittsburgh Medical Center Hamot in Erie, Penn.

C. Liam Dwyer, MD, is an orthopaedic hand and upper extremity surgeon at Geisinger Medical Center in Danville, Penn.

References:

  1. Dibenedetti, D.B., D. Nguyen, L. Zografos, et al., Prevalence, incidence, and treatments of Dupuytren’s disease in the United States: results from a population-based study. Hand (N Y), 2011. 6(2): p. 149-58.
  2. Eaton, C. Dupuytren Disease. In: S.W. Wolfe, et al., eds. Green’s Operative Hand Surgery. Philadelphia: Elsevier; 2017:128-51.
  3. Kan, H.J., E.W. de Bekker-Grob, E.S. van Marion, et al., Patients’ Preferences for Treatment for Dupuytren’s Disease: A Discrete Choice Experiment. Plast Reconstr Surg, 2016. 137(1): p. 165-73.
  4. Wach, W. and G. Manley. International patient survey (part 1: Dupuytren disease). In: P. Werker, et al., eds. Dupuytren Disease and Related Diseases - The Cutting Edge. Switzerland: Springer International Publishing; 2017:29-40.
  5. Ball, C., D. Izadi, L.S. Verjee, et al., Systematic review of non-surgical treatments for early dupuytren’s disease. BMC Musculoskelet Disord, 2016. 17(1): p. 345.
  6. van Rijssen, A.L., H. ter Linden, and P.M. Werker, Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg, 2012. 129(2): p. 469-77.
  7. Mickelson, D.T., S.S. Noland, A.J. Watt, et al., Prospective randomized controlled trial comparing 1- versus 7-day manipulation following collagenase injection for dupuytren contracture. J Hand Surg Am, 2014. 39(10): p. 1933-1941 e1.
  8. Kaplan, F.T., M.A. Badalamente, L.C. Hurst, et al., Delayed manipulation after collagenase clostridium histolyticum injection for Dupuytren contracture. Hand (N Y), 2015. 10(3): p. 578-82.
  9. Coleman, S., D. Gilpin, F.T. Kaplan, et al., Efficacy and safety of concurrent collagenase clostridium histolyticum injections for multiple Dupuytren contractures. J Hand Surg Am, 2014. 39(1): p. 57-64.
  10. Costas, B., S. Coleman, G. Kaufman, et al., Efficacy and safety of collagenase clostridium histolyticum for Dupuytren disease nodules: a randomized controlled trial. BMC Musculoskelet Disord, 2017. 18(1): p. 374.
  11. Collis, J., S. Collocott, W. Hing, et al., The effect of night extension orthoses following surgical release of Dupuytren contracture: a single-center, randomized, controlled trial. J Hand Surg Am, 2013. 38(7): p. 1285-94 e2.
  12. Craft, R.O., A.A. Smith, B. Coakley, et al., Preliminary soft-tissue distraction versus checkrein ligament release after fasciectomy in the treatment of dupuytren proximal interphalangeal joint contractures. Plast Reconstr Surg, 2011. 128(5): p. 1107-13.

Advertisements

Advertisement