Dupuytren Contracture Treatment & Management
- Author: Stephanie Danielle Mathew, DO; Chief Editor: Herbert S Diamond, MD more...
This is appropriate for patients with unchanging, painless Dupuytren disease with minimal contracture and no functional impairment. Patients with mild Dupuytren disease can be monitored on an infrequent basis via a brief follow-up visit every 6-12 months. In addition to accurate measurement of the progression of the contractures, the follow-up also provides an opportunity to elicit a history of any functional deficits. Further, these visits allow assessment and discussion of the need for surgical referral.
Physical and occupational therapy
Stretching with the application of heat and ultrasonographic waves may be helpful in the early stages of Dupuytren contracture. The physical therapist also may recommend that the patient wear a custom splint or brace to stretch the fingers further. Range of motion (ROM) exercises should be performed several times a day. If the patient undergoes surgical correction of the contracture, physical therapy often is involved following the procedure. The postsurgical program consists of wound care, massage, passive stretching, active ROM exercises, and splinting.
Through a course of occupational therapy, the patient may learn adaptive techniques and begin to use assistive devices that enhance functional abilities. For example, adaptive equipment can help a patient to open jars, despite contractures.
Intralesional triamcinolone acetonide (Kenalog-40) injections of 40 mg/mL have yielded subjective improvement in the size of Dupuytren nodules in some patients. Ketchum argues that early treatment of a nodule with an intralesional steroid injection, before the development of joint contracture (particularly PIP joint involvement), can interrupt the inflammatory process and thus the progression of disease.
However, corticosteroids are associated with a high risk of complications, including fat atrophy and skin discoloration. In addition, intralesional injection of corticosteroids can result in tendon rupture.
Radiotherapy can be effective in slowing disease progression in the early stages of Dupuytren contracture but was not effective in advanced disease. Radiotherapy did not reduce the rate of surgical intervention and was associated with a high rate of adverse events.
Prior to February 2010, surgical intervention was the mainstay of treatment for Dupuytren disease despite a high rate of recurrence and complications. In February 2010, the US Food and Drug Administration (FDA) approved collagenase Clostridium histolyticum (Xiaflex) at a dose of 0.58 mg per injection for the treatment of Dupuytren contracture in a single digit during a 30-day treatment cycle. Injected collagenase extracted from C histolyticum weakens and dissolves the Dupuytren cord.[59, 60]
A study by Hurst et al resulted in FDA approval of CCH for the management of Dupuytren contracture. Hurst et al performed a prospective randomized double blind placebo controlled trial investigating collagenase versus placebo for the treatment of Dupuytren disease, with contractures greater than 20º in 308 patients (CORD I and CORD I Extension). Their findings included a reduction in contractures to less than 5º in 64% of collagenase-injected patients compared with 6.8% of patients treated with placebo. Patients with MCP involvement tended to improve to a greater extent, as did those patients with less severe flexion contractures.
Glipin et al performed a 90-day double blind placebo-controlled study with a 9-month open label extension evaluating the efficacy of CCH in Dupuytren disease in Australia, termed CORD II. Sixty six patients were enrolled: 45 in the treatment group and 21 in the placebo arm. The primary end-point was reduction of the contracture to 0-5º of normal, 30 days after the last injection. A statistically significant reduction in contracture was reported in the treatment group, with 44% of patients meeting the primary endpoint with treatment versus 4.8% of controls.
Witthaut et al reported on the efficacy and safety of CCH in 2 open label trials (JOINT I in the United States and JOINT II in Australian and Europe). Patients with fixed-flexion contractures of the MCP or PIP could receive up to 3 0.58-mg CCH injections per cord, with finger extension procedures 24 hours later. Dupuytren cords affecting 879 joints in 587 patients were injected. Clinical success was achieved in 57% of joints (MCP 70% success rate, PIP 37% success rate). The mean change in contracture was 55º for MCP joints and 25º for PIP joints. At least one adverse event was seen in 97% of patients. Most were localized to the injection site. The most common side effects included edema if the treated extremity, bruising, injection site pain, extremity pain, injection site swelling, and hemorrhage. Fifty five cases of skin laceration were reported, along with 34 cases of injection-site vesicles.
Peimer et al evaluated the long-term safety and efficacy of CCH in the CORDLESS study; 1080 patients were enrolled from the original 5 clinical trials (JOINT I, JOINT II, CORD I, CORD I extension and CORD II). Patients were evaluated beginning 2 years after their first injection and then annually for a total of 4 years. Recurrence rate was 35% (MCP, 27%; PIP, 56%). In the original studies 301 joints were partially corrected; 50% of these had a nondurable response (MCP, 38%; PIP, 62%). Anticlostridial type I collagenase and/or anti-clostridial type II collagenase antibodies were reported in 96% or more of patients who had received 2 or more CCH injections and 82% who received one injection. No correlation of antibody titer to adverse events was reported. No new or long-term serious adverse events were noted, although the recurrence rate was noted to be lower in successfully treated joints than in partially corrected joints.
Coleman et al studied the efficacy of CCH when injecting two Dupuytren cords concurrently. The study treated 12 subjects with more than three joint contractures. During the first treatment session, all subjects were injected with single dose of CCH (0.58 mg) into a single cord. Thirty days later, the same patients were injected at two different cords concurrently in the same hand. A mean reduction in joint contracture of 30º was obtained. All patients were satisfied with the outcome, and the rate of adverse events was similar to a single injection. This study suggested that two cords can be treated concurrently with a similar safety profile of treating the individual cords sequentially.
In October 2014, the FDA approved an expanded indication for CCH for the treatment of up to two Dupuytren contracture joints in the same hand during a single treatment visit. A finger extension procedure can be performed at 24, 48, or 72 hours after injection.
Complications associated with CCH are common. In the Hurst et al study, an adverse event occurred in 96% of patients, although only 3 serious reactions were reported. The most common complications included injection site reactions, peripheral edema, bruising, bleeding, and pain. More serious reactions included tendon rupture and complex regional pain syndrome. To date, tendon rupture has been described in 0.3% of 1080 patients.
5-Fluoruracil has been shown to cause a dose-dependent, selective and specific decrease in collagen production by fibroblasts and inhibit fibroblast proliferation and myofibroblast differentiation.[65, 66] However, TGF-beta1 gene expression and procollagen type I and III messenger ribonucleic acid (mRNA) are not affected. After undergoing clinical trials, this treatment may be useful as an adjuvant therapy to surgery in reducing extracellular matrix production and recurrence of Dupuytren contracture.
Imiquimod is an immune modulator that downregulates TGF-beta and fibroblast growth factor-2, which are important cytokines in the pathogenesis of Dupuytren contracture. Immune modification of profibrotic cytokines may be an innovative way to control disease. Imiquimod cream has been proposed as a therapy. However, no reports have described experimental use of imiquimod for Dupuytren contracture.
This has also been proposed as an intralesional therapy for Dupuytren contracture, based on its inhibition of Rho GTPase, which is necessary for the activation of the IL-1 inflammation pathway. As with imiquimod, no reports currently describe clinical use of botulinum toxin for this condition.
Hyperbaric oxygen is another theoretical therapeutic option. Fibroblast and myofibroblast production may cease if hypoxic conditions are reversed by high tissue oxygenation.[15, 69]
The goal of surgical care is to excise the diseased fascia to help prevent progression of the disease. A patient should be referred to a hand surgeon if the MCP contracture is more than 30º or if any contracture of the PIP is present. Functional disability may be an indication for surgery if the patient accepts the associated morbidity and understands that surgery may not be curative. As with all elective surgeries, the patient's age, comorbid conditions, and ability to comply with postoperative care and rehabilitation also determine whether surgery is appropriate.
Surgical interventions consist mostly of fasciectomy. Complete extension of affected joints may be possible with earlier intervention. However, any degree of PIP contracture carries a poor prognosis, and excising the involved fascia may not correct the joint contracture, especially if it has been long standing. MCP involvement is more amenable to surgical correction than PIP involvement, even in more advanced or long-standing cases. Subsequently, surgery is recommended as soon as a PIP contracture is detected.
A study found that improvement in the PIP joint contracture has a greater correlation with hand function at 6 and 12 months after surgery than does improvement in the MCP joint contracture.The results of another study revealed the severity of contracture preoperatively had a significantly negative effect on hand power, and older patients experienced less functional benefit from selective fasciectomy. In bilateral cases, the initial operation is on the worst or dominant hand. If indicated, the other hand can be operated on 6-8 weeks after healing of the first hand.
If a patient needs to undergo surgical fasciectomy for Dupuytren disease and also requires a carpal tunnel release for carpal tunnel syndrome, a study recommends that both procedures be done concomitantly, as the complication rate is not significantly increased.
For more information, see Surgery for Dupuytren Contracture.
Surgery versus collagenase injection
In a study that compared CCH injection versus limited fasciectomy in 132 patients with Dupuytren contracture, Zhou and colleagues reported no significant difference in the degree of residual contracture of the MCP joint (13° with CCH versus 6° with surgery; P = 0.095). With PIP joint treatment, residual contracture was significantly worse with CCH (25° versus 15° with surgery; P = 0.010). However, patients treated with CCH had more rapid recovery of hand function and experienced fewer serious adverse events than did those treated with fasciectomy.
Surgical intervention may be appropriate in more severe cases. Consider surgical consultation with one of the following specialists:
Orthopedic hand surgeon
Stretching with the application of heat and ultrasonographic waves may be helpful in the early stages of Dupuytren contracture. The physical therapist also may recommend that the patient wear a custom splint or brace to stretch the fingers further. ROM exercises should be performed several times a day. If the patient undergoes surgical correction of the contracture, physical therapy often is involved following the procedure. The postsurgical program consists of wound care, massage, passive stretching, active ROM exercises, and splinting.
Through a course of occupational therapy, the patient may learn adaptive techniques and begin to use assistive devices that enhance functional abilities. For example, adaptive equipment can help a patient to open jars, despite contractures.
Percutaneous needle fasciotomy/closed fasciotomy
Percutaneous needle fasciotomy (PNF) is a minimally invasive treatment that is usually performed as an office procedure under local anesthesia. It involves multiple puncture sites and sectioning of the Dupuytren cord using the bevel of a needle.[74, 75, 76, 77]
Needle fasciotomy may be an effective initial intervention in the treatment of Dupuytren contracture either alone or as a first step to subsequent procedures such as repeated fasciotomy, fasciectomy, or CCH injection.
In a study of 211 older patients (average age 65 y), investigators found a single digital nerve injury, no infections, and no tendon injuries with needle aponeurotomy, although damage to the neurovascular bundle is a concern. Recurrence rates (58%) and disease activity (69%) were high at 3-year follow-up.
Foucher et al believed this technique was ideal for the elderly patient with a bowing cord and a predominant MCP joint contracture. Needle fasciotomy may also facilitate hygiene in a debilitated elderly patient. Limitations of fasciotomy in treating PIP joint contracture were noted.
Contraindications to PNF include infiltrating disease; rapid recurrence in a young patient; inaccessible, multiple cords; chronic digital disease; and postsurgical recurrence in the digits.
An open fasciotomy is sometimes used to manage more severe cases of Dupuytren contracture, and is more effective in the long-term when compared with needle aponeurotomy. Open fasciotomy is still an outpatient procedure performed under local anesthesia. An incision is made over the diseased cord and direct visualization of the cord and neurovascular structures is possible. The offending cord is divided at a point immediately underlying the skin incision.
Fasciotomy is usually most successful for MCP flexion contracture. The recovery is rapid, but the recurrence rate is high. Open fasciotomy is usually reserved for patients who cannot tolerate a more extensive procedure.
Segmental aponeurectomy of Moermans is a procedure that is intermediate between simple fasciotomy and limited fasciectomy. Segments (1 cm in length) of fascia are excised through C-shaped incisions.[80, 81]
Regional (or selective) fasciectomy
This involves excising only the fascia that is grossly affected (eg. in the palm, pretendinous cords and involved natatory ligaments; in the fingers, only those structures that are visibly affected). Although the disease process clearly extends into clinically normal palmar fascia, this approach has proven successful in correcting MCP joint contractures and some PIP contractures and carries an acceptably low morbidity rate.
Areas not treated may develop disease. This method is commonly used to treat primary and recurrent disease. Skin incisions may be transverse, longitudinal, or diagonal/zigzag (eg, Z-plasty, Y-V-plasty, Bruner-type zigzag incision). Local advancement flaps, including an ulnar-based skin flap and palmar inter-metacarpal flap have been described.
In a study of selective fasciectomy, Hueston concluded that this procedure does not prevent recurrence of Dupuytren disease but does allow correction of deformity with more rapid recovery of hand function.
Extensive or radical fasciectomy
This involves excision of the entire palmar fascia, including tissue that appears grossly healthy (in an effort to prevent recurrence). Although this procedure is not commonly performed today, it results in a relatively low recurrence rate of about 11%. It does have an increased risk of morbidity postoperatively, including hematoma in 14% of cases and nerve irritation or damage in 6%. Patients are also prone to prolonged postoperative edema and stiffness. One study concluded that total aponeurectomy was most appropriate for stage 2 disease.
This removes the diseased fascia and the overlying skin. The wound is then resurfaced and a full thickness skin graft is applied. Recurrence rates are low, being similar to those of extensive fasciectomy. Because of the radical nature of this procedure, it is usually reserved for patients with recurrent or severe disease.
In dermofasciectomy, two incisions are made, one from the distal interphalangeal joint of the affected digit to the distal palmar flexion crease, and a transverse palmar incision, to form an L shape. A selective fasciectomy is performed, with partial closure of the incision site. A full-thickness skin graft is harvested from the hypothenar eminence during this surgery. A portion of the palm is left open, and an extension splint is applied. After 4 days, the splint is removed, the wound is cleaned, and the skin graft is applied to the palm. The palm is splinted again for 1 week.
General recommendations for surgical intervention
A fasciotomy or regional fasciectomy is usually sufficient to establish normal function in the MCP joint. The procedure of choice for PIP joint involvement is either dermofasciectomy or extensive fasciectomy.
Amputation may be recommended if digital contracture is greater than 90º or if vascular compromise has developed. Some patients may prefer amputation to the postoperative care required for fascial surgery.
The surgeon and the patient may choose general or regional anesthesia during the procedure. Loupe magnification is used to aid visualization and detection of the delicate structures, specifically the neurovascular bundle.
A pneumatic tourniquet is typically used on the operative extremity to control blood loss and assist with visualization.
Incisions vary and may be transverse, zigzag, or longitudinal, depending on the region involved. The skin is separated from the underlying diseased palmar fascia and all neurovascular bundles that may be jeopardized during dissection are identified. The neurovascular bundles are often displaced or distorted by the contraction of the components of the palmar fascia.
After each neurovascular bundle has been identified and dissected away from the diseased palmar fascia, the diseased fascia is excised. The MCP joint is often fully corrected with this maneuver. PIP joints may have residual flexion at this stage and may require release of the flexor tendon sheath, as it can become shortened with chronic contracture.
The skin is closed with running or interrupted absorbable or non-absorbable suture material. A modified skin closure with Z-plasty or V-Y advancement can provide additional length without undue tension. If skin grafting is necessary to close the wound, use a full-thickness graft to minimize wound contracture during healing. Postoperatively, bandage the hand and place it in a splint.
Skin overlying the contracture is closed either primarily (using skin grafts) or by secondary intention.
The open-palm technique (McCash technique) involves a transverse skin incision and division of the aponeurosis; healing is by secondary intention.
A modification of the McCash technique, called the Jacobsen flap, uses the L -shaped incision of dermofasciectomy, but healing is by secondary intention.
The synthesis technique is a method of wound closure that incorporates the advantages of tissue rearrangement, the open-palm technique, and full-thickness skin grafting. One study showed a decreased healing time and recurrence rate using the synthesis technique versus the traditional open-palm technique.[87, 88, 89]
Routine postoperative care is essential for an optimal outcome. Immediately following the procedure, a splint should be applied dorsally to avoid excess pressure on the incision site. The hand should be placed in extension with flexion of the MCPs and extension of the PIPs. Initially, the splint is worn continuously, with removal only for dressing changes and exercise. Patients who undergo PIP surgery should wear the brace for 6 weeks on a continual basis and may require 3 months of bracing to minimize scar contractures.
The overall goal of splinting is to provide a prolonged stretch to the tissues and prevent flexion contractures. Splinting is modified over the next 8-10 weeks to accommodate range of motion, with the splint worn primarily at night.
A specific exercise regimen with an occupational therapist should be instituted with range-of-motion exercises 1 week postoperatively. A rehabilitation program is critical for successful management of these patients; it helps to reduce swelling, improve wound healing, and restore finger mobility and function.
Rehabilitation following surgery is a gradual process of increasing activity and decreasing splinting to achieve increased range of motion. According to one study, therapy that avoids applied mechanical tension in the early postoperative phase results in fewer complications, with no digital motion lost to extension.
The occupational therapist regularly records the patient’s degree of extension to assist in monitoring the patient’s progress. Maximal results are evident 6 weeks postoperatively. Return to normal activity is expected in 2-3 months.
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