What is Dupuytren's Contracture?

Dupuytren's contracture is a progressive fibrous proliferation of the palmar fascia of the hand. It is a tumor (growth) but not a cancer.  Similar type fibrous fascia growths may also occur in the fascia of the feet and there it is called Ledderhose disease. There is no known cause or etiology for Dupuytren's.  It is considered an inherited condition and not related to work or hand use.  The disease is metabolic and genetic in nature.  Dupuytren's is often observed in persons of Northern European descent, especially Scandinavians. It is sometimes called the "Viking" disease although the "Viking" theory of disease and spread is disputed by some authors [1, 2]  Diet does not seem to have an effect, or change Dupuytren's although diabetics have a higher incidence of the disease[3]. The disease occurs worldwide in all races, but is most concentrated in Scandinavia.  I have personally treated Africans and Chinese with this disease.  Dupuytren's is found more commonly in men[4-6].  There does not seem to be a specific relation to labor or work[7], and it is not covered by workers compensation, although exposure to vibration may increase the risk of developing Dupuytren’s[8].  In a study in Norway, Dupuytren’s was more common in those that labored with their hands rather than those with sedentary work[9].   A French study also confirmed slightly higher Dupuytren's in those that labored with their hands[10].  The cause of the disease is unknown and it usually presents later in life.  It has been reported in children[11-15].   Trauma, such as a fracture has been reported to bring on Dupuytren’s[16].  It often starts as nodule in the palm that is composed of fibroblasts. After this, the nodular growth may start connecting and contracting. One will notice pits or grooves in the skin and there may be associated pain or tenderness. Microscopically, myofibroblasts may be found and these are the cells that start the contracture. At this stage, the composition shifts to more type III, and type V collagen. Late stage Dupuytren's is characterized by metacarpophalangeal (MCP or first joint), proximal interphalangeal (PIP or middle joint), and rarely distal interphalangeal (DIP or distal joint) contractures.   The disease most commonly affects the ring finger, and the little finger is second most commonly affected.  Correction of little finger PIP joint contractures (middle joint) are the most difficult to treat even with all the tools available to modern medicine such as needle aponeurotomy, surgery, skin grafting, or XIAFLEX (collagenase) which dissolves the cords. Thumbs, index, and middle fingers may also be affected in some patients.

Associated conditions

Peyronies disease, knuckle pads(Garrod nodes), plantar fibromatosis (Ledderhose disease). Trigger fingers (stenosing tenosynovitis) may also occur in association with Dupuytren's.  Heavy smokers, drinkers, and diabetics have an increased risk of Dupuytren's[17]  However, most patients with Dupuytren's contracture are not smokers or drinkers and do not do manual labor.

Incidence

A large study in the US Veterans hospitals of 9938 patients found an incidence of 734 per 100,000 population in whites, 237 per 100,000 in Hispanics, 130 per 100,000 in blacks, and 67 per 100,000 in Asians[18].  In the United States the incidence in white populations is about 3%.  In Norway, the incidence is about 30%-40%[6, 19].    The disease is very rare in African Blacks[20]. 

History

Dupuytren’s contracture, named after Baron Dupuytren the French Surgeon who detailed the condition in a lecture in 1831.  Dupuytren showed the contracture was from the fascial of the palm of the hands, and not as a result of tendon contracture.  It has been an enigma for centuries. Due to the low incidence in Southern Europeans, no record of Dupuytren’s is found in ancient Greek and Roman medical books.  Dupuytren was not the first to discover this disease but the condition is named after Dupuytren as he clearly showed in anatomical dissections that the contracted fingers were not because of a tendon problem, but rather a build-up, fibrosis, and contracture of the palmar fascia.  The first documented cases in the European literature was the case reported by Plater in 1614.   After Plater, it was Henry Cline (1750-1826) that rediscovered this condition[21].  A French surgeon, Alexis Boyer, described “crispatura tendinum” in 1814.   Boyer felt the contracture problem was a disease of the flexor tendons. Astley Cooper, from England, a contemporary of both Boyer and Dupuytren also described contracted palms in 1822 and correctly proposed its treatment before Dupuytren.  Dupuytren takes the name of the condition as he clearly delineated the contracture is related to the palmar fascia[21].  Dupuytren recognized that it was a contracture of the palmar fascia or palmar aponeurosis and presented his anatomical work in 1831[22]. He proposed the surgery fasciotomy (an incision of the contracted tissues) to correct the contracture.  A few years later Dr. Goyrand, also in Paris proposed longitudinal opening and excision of the diseased tissue[23].  Dupuytren's approach, the release the fascia with small cuts, was the original technique used to treat Dupuytren’s, however it was noted decades before Dupuytren’s description by Dr. Cline in England and later by Dr. Cooper, also in England.   

Surgical treatment of Dupuytren’s

Needle fasciotomy (otomy=opening, fasciotomy is opening of the fascia) also called needle aponeurotomy, NA, or needle aponevrotomy is a technique developed and refined in France by Rheumatologists Lermusiaux, Badois and others since the 1970's[24, 25].  It involves cutting the tight contracted Dupuytren's cord under local anesthesia as on office procedure using hypodermic needles instead of a scalpel. Small needles are used to release the cords in multiple areas, and then the cords are popped as the finger is straightened. This technique has been reported in the British Journal of Hand Surgery[26]  There was a low incidence of nerve injury (0.3%) and no tendon injuries. They also found significant gain in extension at the MCP joint and also good improvement at the PIP joint. The need for reoperation at average follow up of 3.2 years was only 24%.

The most common complication of needle aponeurotomy is skin openings that occur with rupture of the Dupuytren's cord. This occurs about 16% of the time and may require a suture or can be left open to heal[26].  The diseased Dupuytren's tissue is not removed, but is only incised or nicked. Recurrence at 5 years is reported to be 50%[25]. The good news is that needle aponeurotomy may be repeated if recurrence develops, or the new enzyme, XIAFLEX, could be injected into recurrent areas of Dupuytren's. 

A great advantage of this technique is the lack of hospitalization, outpatient surgery centers, or an anesthesiologist. The small needles provide little trauma to the tissues and if done in areas where the skin is pliable, skin tears do not occur. Healing is rapid. The initial bulky dressing may be removed after a day or two and then may only require Band-Aids. Formal physical therapy is not usually necessary unless the middle joint (PIP) is severely bent.  Surgical removal of Dupuytren's frequently requires therapy. However, needle aponeurotomy only separates the bands. Scar tissue may reform and start the contracture again. It is important to do finger stretching frequently to maximize the results. In the beginning, this may be difficult due to the recent procedure. As weeks pass, aggressive hyperextension can prevent the severed cords from re-connecting.   I am in favor of stretching to prevent and slow down the recurrence of Dupuytren's.  Dupuytren's occurs in the feet and is called Ledderhose disease.  Despite severe trauma to the foot over a lifetime and constant overstretching of the toes with each step, the toes do not curl underneath.  Therefore, I believe lack of stretching, or bending back of the fingers is more of a problem in the hand.  I encourage my patients to fight the Dupuytren's from contracting. 

Subcutaneous Fasciotomy

This technique was first suggested by Dr. Astley Cooper in 1822 for the treatment of fascial contractions of the finger i.e. Dupuytren's. Dr. Cooper stated: but when the aponeurosis is the cause of the contraction and the contracted band is narrow, it may be with advantage divided by a pointed bistoury (scalpel), introduced through a very small wound in the integument. The finger is extended and a splint is applied to preserve it in a straight position." From Cooper, A: Treatise on dislocations and on Fractures of the Joints, Ed. 2 p. 521 Longmans, London 1823. The open fasciotomy of Dupuytren involves cutting straight down through the skin and fascia and avoiding the tendons which are deep. The subcutaneous fasciotomy, like the needle aponeurotomy cuts the contracted tissues under the skin and doesn't usually leave any major skin openings. Articles reporting on the success of blind scalpel aponeurotomy with great success include the works of Kelly in 1959[27] , and Luck[28] Kelly's article from 1959 in the Plastic and Reconstructive Surgery Journal stated very strongly as to why major surgical approaches are undertaken when the results from subcutaneous release can be so good. The quote from Kelly is below"

"Subcutaneous fasciotomy" was first suggested for the treatment of flexion contracture of the fingers by Sir Astley Cooper in 1822. He wrote "... but when the aponeurosis is the cause of the contraction and the contracted band is narrow, it may be with advantage divided by a pointed bistoury, introduced through a very small wound in the integument. The finger is extended and a splint is applied to preserve it in a straight position". This procedure fell into disrepute through the years because it was indiscriminately applied to all cases of contracture; but Luck, 1958, has recently reintroduced it and it has achieved limited popularity. Having perused 20 papers, published since Skoog's monograph in 1948, on the surgical treatment of flexion contracture, we find that fasciotomy is either not mentioned at all or condemned. The radical fasciectomy, on the other hand, is given not merely as the procedure of choice but is considered the only satisfactory surgical treatment. This blind adherence to a single procedure for the treatment of a disease that has many individual variations and several stages of development shows an infatuation with a technical exercise that does not properly answer each patient's need.

The current technique of needle aponeurotomy, developed in France for the flexion contracture of Dupuytren is a type of subcutaneous fasciotomy.

Subcutaneous fasciotomy was the predominant treatment for Dupuytren's till the 1900's.  At that time, with improvements in anesthesia and surgical technique, excision of Dupuytren's, fasciectomy, became the normal treatment.  Radical excision of Dupuytren's, removing all palmar fascia, both diseased and normal tissue as a prevention fell into disfavor in the 1960's due to the complications associated with this surgery.

Segmental Fasciectomy

A scalpel excision (removal or fasciectomy; ectomy=excise) of a short segment or piece of a contracted Dupuytren's cord. This technique was developed by Moermans[29, 30]

He has reported favorable long term results and this is the most non-invasive surgical technique. Patients with previous surgery on Dupuytren contracture may need segmental surgical releases as needle fasciotomies or NA are less effective after previous surgery.

It is very useful on the thumb, as it is difficult to release thick thumb cords which lie over the digital nerves. In many cases, a small incision, under local anesthesia, will break up the contracting cord.A bigger surgery than needle releases, recovery will take weeks or even a month or two. Formal physical therapy is not usually required as it is after a limited fasciectomy.

Limited fasciectomy

The most common surgical procedure performed in the USA and also very common in France[31].  An excisional technique removing diseased areas of Dupuytren’s. It is normally performed under general anesthesia or nerve blocks and a mechanical tourniquet. The McCash technique is a limited fasciectomy that is left partially open in order to prevent postoperative bleeding[32] [33, 34].

Dermofasciectomy

A technique that involves cutting out the diseased Dupuytren's with its overlying skin and replacing the defect with a skin-graft taken from somewhere else. It was popularized by Hueston[35].  The new transplanted skin seems to prevent recurrence of Dupuytren’s. This surgery can be very useful in scarred and recurrent Dupuytren’s. Another technique developed by Hueston is the “firebreak” graft which is a skin-graft placed between excised or ruptured bands of Dupuytren’s to prevent the cord from redeveloping.  The success of this procedure is based on the fact that Dupuytren's does not readily recur under a skin graft[36-40].  

Radical Fasciectomy

Radical fasciotomy is a historical technique. It was developed and proposed by McIndoe[41].  It involves cutting out all disease Dupuytren's cords and normal palmar aponeurosis. This is to prevent recurrence of the disease by removing all palmar fascia which could turn into contracted Dupuytren's nodules or fibrosis. The operation has a high complication rate and is rarely performed nowadays.  

Medical (non-surgical) Treatment of Dupuytren's 

Enzymatic dissolution of Dupuytren's via the product XIAFLEX (collagenase) is FDA approved since February 2010.  Treatment requires injections of the the Xiaflex enzyme followed by breaking of the contracting cords of Dupuytren’s the next day or week.  The first use of clinical collagenase was for burns.  Now, it is approved for Dupuytren's, and possibly in 2011 for Peyronies disease.

Collagenase (Xiaflex) will work best in the palmar area of the hand.  It may take more than one injection episode, and it is not recommended for use at the middle joint of the finger.  However, excellent improvement can occur in the middle (PIP) joint as the tethering Dupuytren's cords are leased.  Needle aponeurotomy will likely still be used to help those afflicted with more distal disease.  Needle and XIAFLEX are an excellent combination.  XIAFLEX (collagenase) injections don't seem to injure nerves, but there is a remote risk of tendon rupture from Xiaflex (the actual risk in FDA clinical trials was 00.3% for tendon rupture).  The limitations of Xiaflex are that it only treats one segment of one cord, at one time, and it takes two visits at a minimum.  Use of the drug 30 days later is performed to touch up and re-treat residual areas of Dupuytren's.  The drug is very powerful, but highly useful. After the injection there is a lot of swelling and bruising. There can be redness, itching, and pain up the arm into the armpit days after the injection. Long term after Xiaflex injections the disease can continue to grow in areas not involved.

To see if your insurance covers Xiaflex treatments, please call for pre-approval: 

1-877-XIAFLEX (1-877-942-3539)

TABLE OF RISK OF DUPUYTREN’S TREATMENTS

Alternative Medications

Some medications that have been tried are allopurinol[49-51] , colchicine[52, 53], vitamin E[49, 54-59], calcium channel blockers[60], interferon[49, 61, 62], DMSO[49, 63, 64], and NAC (N-acetyl-L-cystein)[65, 66]. None of these alternatives have been shown to be consistently effective.

Radiation Therapy

Radiation therapy is helpful in preventing progression of the disease and may have some use in preventing contractures or keeping fingers straight after treatment[67-69].  Radiotherapy should be done when the fingers are straight and therefore preliminary needle aponeurotomy or enzyme treatments would be necessary to straighten the fingers.  Radiotherapy would then be performed to prevent recurrence although 31% of patients with Dupuytren’s continued to progress despite radiation[67].

Ledderhose Disease 

A condition related to Dupuytren's of the hand but it occurs on the fibrous fascia of the feet. It also may be treated with needle release. Since there are usually no contracted toes the results are not as dramatic as one finds in the NA of Dupuytren's of the fingers. Ledderhose disease needle aponeurotomy requires optimally two visits separated 2-3 weeks apart to perform NA and settle down the painful nodules.

For more information visit the Dupuytren contracture forum:

http://www.dupuytren-online.info/Forum_English/board/dupuytren-0.html

Dr. Eaton's Dupuytren's Foundation BlogSpot

http://dupuytrenfoundation.blogspot.com/

Or Auxilium's website, the Xiaflex company:

http://dealingwithdd.com/

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