Dupuytren’s disease (also known as Dupuytren’s contracture) is a condition whereby there is an overgrowth of collagen type tissue just below the skin of the palm. This tissue forms thickened nodules and cords within the palm and a progressive contracture (flexed posture) of the fingers can occur. The little finger is affected most commonly but any finger or the thumb can be involved. The condition is relatively common, affecting almost one in ten Northern European males over the age of 65 but it can present in adult men and women at any age.
Since the condition was first treated by Baron Guillame Dupuytren in 1831 there has been considerable research in to the causes and treatment of the disease. Some causation theories have stood the test of time whereby others have been discarded due to lack of supporting science. What we do know is there is strong genetic (familial) predisposition to the condition but other factors may contribute to starting the disease in susceptible people. Examples of these include smoking, alcohol, liver disease, diabetes, epilepsy and previous injuries to the hand.
The condition can also lead to thickened pads on back of the finger joints known as Garrod’s pads. An identical condition can also affect the sole of the foot (known as Ledderhosen’s disease) and the male penis (known as Peyronie’s disease).
Treatment Options for Dupuytren’s Disease
Due to the fact that the underlying cause of Dupuytren’s is genetic no treatment can cure or prevent the condition and sadly recurrence is possible after any treatment method. It is best to avoid surgery in the early stages where nodules are present but the fingers are not yet contracted because in some cases the treatment, in particular surgery, can act as a trigger to more rapid spread of Dupuytren’s in the hand.
Multiple treatment methods have been described, but to date despite articles in the popular tabloid press there is no strong evidence to support the use of oxygen, ultrasound, or radiation in the treatment of Dupuytren’s.
There is good evidence to support the use of a special injection of an enzyme, called collagenase, into the contractures, which can then be manipulated in clinic 24 – 48 hours later, without the need for surgery. Collagenase injections (tradename “Xiapex”) work well in certain cases. This can be discussed further with Mr Murray in your consultation.
A reliable and predictable method of treatment is surgery, and once a contracture has reached the stage where the hand can no longer be placed flat on the table, or the finger is “getting in the way”, then this is usually the time to consider intervention, either with injection or surgery.
Surgery for Dupuytren’s Contracture
In essence the options available are to simply to divide the thickened cord of tissue (fasciotomy), to divide and remove the thickened cord (fasciectomy) or to divide and remove the thickened cord and the overlying involved skin (dermo-fasciectomy).
The most straightforward operation is known as a “fasciotomy”. This is suitable where the contracture is mainly in the palm, rather than in the fingers. It involves a Local Anaesthetic injection, and a small incision in the palm, then dividing the cord of tight tissue that is stopping the finger from straightening. An alternative method is to use a needle through the skin to divide the cord and this can be performed in the Hand Clinic by Mr Murray, if indicated. The wound in the palm heals without stitches over 2-4 weeks and a plastic splint is used at night for three months, to keep the finger straight. This small procedure has minimal risk, and most patients are back to full functional activity after a few days.
If the contracture is more extensive, then a “fasciectomy” may be recommended. It may be performed under a Local Anaesthetic, Regional Anaesthetic (numbing the whole arm) or General Anaesthetic. Usually, a zig-zag incision is used in the hand, and the affected tissue in the hand and fingers is excised.
In special situations such as very aggressive disease, Dupuytren’s in young people or in “re-do” cases when surgery has been performed previously, a “dermo-fasciectomy” will be recommended. This involves removing some of the skin of the finger / palm, as well as the Dupuytren’s tissue. The skin is replaced with a skin graft, taken from near the elbow or wrist. A plaster cast is used for 2 weeks, to protect the graft.
The hand is kept elevated for the first 48 hours, to reduce any swelling. After 2 weeks, the stitches can be removed and a small plastic splint will be made to measure, and worn for 3 months, but at night only.
Outcomes of treatment
Most patients have a good result following surgery, with better hand function, and correction of the initial deformity.
Are there any risks?
- It is sometimes not possible to fully straighten the finger, especially if there has been a severe (over 60°) or long-standing contracture.
- There is a small (~1%) risk of wound infection, which usually settles with antibiotics.
- There is a small (~1%) risk of damage to the nerves and blood vessels in the fingers.
- There is a very small (<1/1000) risk of losing the circulation to the finger, which may lead to amputation of part of the finger. This risk is higher in smokers and in re-do surgery. Mr Murray will advise you if your finger is at particular risk.
- Scars may be tender, and there may be some stiffness. Both of these are treated with physiotherapy.
- Chronic Regional Pain Syndrome “CRPS”. This is a very rare but serious complication, with no known cause or proven treatment. The nerves in the hand become hyper-sensitive, and can cause swelling, pain, discolouration and stiffness, which very slowly improve, but may leave stiffness. This is treated with physiotherapy and painkillers.
- If a skin graft is required then there is a small chance that this will not “take”. Usually this is only a small area, and can be treated with dressings. Very occasionally the graft would need to be repeated.
- There is a chance of the Dupuytren’s contracture recurring, requiring further surgery in the same area.