Dupuytren's Contracture
What is Dupuytren’s Contracture?
Dupuytren’s contracture is a harmless, genetic condition that affects the fibrous tissue in the hand. There are ~ 20 genes known to cause Dupuytren’s contracture. It was named after Baron Guillaume Dupuytren, a French surgeon in 1831 (image below).
In Dupuytren’s contracture, the normal fascia (fibrous tissue) becomes thickened with cells that are a combination of fibrous & muscle tissue. Slowly a contracture of the finger can develop. Most often the ring and small fingers are affected. It occurs in people of northern European ancestry and is more common in men than women. The average age that people seek medical advice for this condition is approximately 60 years for men and 70 years for women. Occasionally it can occur in younger people.
Phone
02 6185 2705
Fax
02 6185 2705
Location
Suite 4A, Level 2
Peter Yorke Building
173 Strickland Cres
Deakin ACT 2600
What causes Dupuytren’s contracture?
Dupuytren's disease is a genetic condition. Every person who has Dupuytren’s contracture has at least one of the 20+ genes that cause the condition. It particularly affects people of Anglo-Celtic heritage and is more common in men than women.
Factors that are known to stimulate the growth Dupuytren's contracture include:
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Diabetes
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Smoking
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High alcohol intake
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High exposure to vibrating tools
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Injury to the hand
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Surgery to the hand (Surgery of small nodules is therefore not recommended.)
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Medications for epilepsy
What are the symptoms and signs of Dupuytren's contracture?
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A firm nodule in the palm is usually the first symptom. Occasionally the nodules can develop in the finger first, sometimes leading to a misdiagnosis.
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Pain is not a feature of Dupuytren's contracture but there can be tenderness for up to 6 months during periods of growth.
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Contracture of one or more fingers may gradually develop from a thickened cord under the skin.
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Garrod's knuckle pads - a small percentage of people with Dupuytren’s contracture develop painless nodules on the back of the knuckles of the small joints of the fingers.
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Lederhosen’s Disease - thickened painless nodules may rarely occur in the arch of the foot.
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Peyronie’s Disease - less than 1% of patients with Dupuytren's contracture develop a contracture affecting the penis. This can be corrected with surgery.
Dupuytren's contracture
Garrod's knuckle pads
Lederhosen disease
What are the risk factors for more severe disease?
The average age of onset in men is early 60s and women, early 70s. Onset late in life often results in slow progress and may never need treatment or may only need non-operative treatment.
Features that predict a more aggressive form of the disease include:
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Younger age of onset.
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Family members with Dupuytren's contracture.
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Painless nodules on the back of the knuckles called "Garrod’s knuckle pads".
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Nodules in the arch of the feet called “Lederhosen’s Disease”, which rarely need treatment.
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Contracture of the penis called “Peyronie’s Disease”, occurs in less than 1% and can be corrected with surgery.
What can I do to prevent Dupuytren's contracture?
Dupuytren's contracture is a genetic condition and there is no known treatment to prevent it progressing. The rate at which the contracture develops varies enormously from person to person.
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Minimize the factors known to stimulate contracture development - alcohol, smoking, diabetes etc (above).
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There has never been any benefit demonstrated in preventing contractures recurring by wearing a splint or performing stretching exercises (these may actually promote disease progression).
When does my Dupuytren's contracture need treatment?
No treatment is advised until a contracture of 30-40° . The palm can no longer be placed flat on a flat surface. Known as Hueston’s tabletop test (photo on right), this is the easiest measure to This usually occurs when there is a contracture. Removal of nodules without a contracture can stimulate the growth of Dupuytren's disease and is not recommended.
What are the treatment options for Dupuytren's contracture?
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Percutaneous needle aponeurotomy (PNA)
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Fasciectomy
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Fasciectomy with full thickness skin graft
What is percutaneous needle aponeurotomy (PNA)?
PNA is a minor office procedure that will improve a contracture for 3-5 years.
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Antiseptic is applied and local anaesthetic is injected to numb the skin over the contracture.
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A fine needle is inserted into the contracture using the sharp bevel of the needle bevel as a knife. Multiple small cuts are made in the fibrous tissue. Consider this like cutting a "rope" under your skin.
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Once the fibrous cord (rope) has been weakened, the finger is gently manipulated to correct the contracture.
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This procedure takes approximately 30 minutes and is performed in the office with the patient seated.
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Occasionally small wounds may result from skin tearing during the manipulation - a light dressing may be required for 2-3 weeks.
PNA is not suitable for everyone
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Thick Dupuytren’s tissue expanding across the width of the finger and severe contractures are not suitable.
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Surgery is often recommended for patients under 65 years as recurrence does not usually occur for 10-15 years.
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In elderly patients PNA may be the only treatment required, but in younger patients it is expected that the disease will slowly progress, and surgery may be required in 3-5 years.
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A consultation and examination are required to assess patient suitability for PNA.
Before the procedure
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No aspirin, anti-inflammatories, or anti-coagulants for 1 week prior to the treatment.
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Check with your GP that it is safe to do so. They can cause excessive bleeding/hematoma formation.
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Restart medication 2 days after the treatment.
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If you have any concerns, please contact your GP/cardiologist.
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We recommend that someone accompany you in case oflight-headedness after the procedure.
After the procedure
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You will see a hand therapist for a splint and stretching exercises immediately after your PNA procedure.
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Your hand must be kept clean and dry for 48 hours (or until any skin tears heal).
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Panadol is recommended for the 48 hours after the procedure.
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Driving and most normal activities can be resumed 24 hrs following the procedure.
Why is collagenase (Xiaflex) no longer used?
Collagenase is an enzyme that dissolves collagen. Fibrous tissue and Dupuytren's contracture are made of collagen. Collagenase was injected into the Dupuytren’s tissue to dissolve small areas of tissue and correct contractures, as an alternative to PNA (above).
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In 2020 the cost of this enzyme increased from ~$1200 to ~$10,000 for a single injection.
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Like PNA, collagenase was a temporary treatment that lasted only 3-5 years.
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Research comparing PNA and Collagenase showed that the outcomes were very similar but the complications and cost were higher for collagenase.
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The recent marked increase in price have ended its use in Australia.
What new treatments are on the horizon?
Research into low dose radiation to prevent Dupuytren's contracture occuring. Previous radiation protocols for Dupuytren's disease have caused significant tissue injury that has led to poor wound healing, infection and other complications when patients who have eventually required surgery. Newer protocols are more promising. If you wish to enrol in the Australian trial for low dose radiation, please contact Hunter Hand Surgery. Dr Tanya Burgess is a senior investigator in this research program. The trial is available at most major centres in Australia.
In the future, genetic therapies may be able to modify the genes that cause Dupuytren's contracture.
What is limited fasciectomy surgery?
Fasciectomy is a day surgery where the abnormal Dupuytren's tissue causing the contracture is removed to straighten the fingers.
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It is a day surgery procedure under general anaesthetic.
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Zig-zag incisions are used as straight incisions in the finger will create a scar contracture.
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Long acting anaesthetic in the hand means that there is very little discomfort and the hand is numb for ~ 8 hours.
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The hand is bandaged and a splint applied to keep the finger/s in the straightened position for 2-3 days.
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A small drain may be used to prevent blood collecting under the skin. The drain is removed before leaving the hospital.
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It is impossible to remove every cell of fibrous tissue from your hand and any cell can transform into Dupuytren's disease and start growing. This is why the procedure is called a "limited" fasciectomy.
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Complet correction of severe contractures may not be possible and the expected outcome will be discussed with you prior to surgery.
Recovery
Each person responds to surgery differently. Recovering the movement in your hand in the first 3 months is a priority because scar tissue becomes very strong by 3 months. This means that it is MUCH more difficult to regain movement after 3 months.
2-3 days
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Hand therapist appointment.
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Bandages and splint removed. Light dressing applied.
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Exercises started.
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Splint will be made to wear at night.
2 weeks
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Stitches removed.
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Commence use of a heat pack before exercises.
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May start hand washing if wounds dry and healed.
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Driving resumes - depending on the extent of surgery.
6 weeks
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Night splinting stopped.
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Using hand for most normal activities
3-4 months
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Exercises continue several times daily
- Swelling and stiffness continues to resolve
- Strength returns
4-6 months
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Residual swelling and stiffness resolve.
IMPORTANT
For the best outcome, follow these instructions for 3 months
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Panadol Osteo or panadol 2 tablets , three times daily. While you may have no pain at rest, doing your exercises will be painful if you do not take pain relief. Consider simple pain relief as essential to regain your hand movement.
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Coban or a neoprene sleeve day and night. Compression reduces swelling which improves movement.
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Heat before every exercise session with a heatpack, shower or water. This reduces pain and improves flexibility.
Full-thickness skin graft for Dupuytren's contracture
Full thickness skingrafting is a day surgery used to decrease the risk of recurrence in patients with severe, early onset or recurrent Dupuytren's contracture.
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In severe Dupuytren’s disease, particularly when surgery has been performed previously in the same area, skin grafts may be required.
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Full thickness grafting has been shown to significantly reduce the risk of recurrent contract.
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The skin graft acts as a "firebreak", as the skin from the groing does not contain the cells that develop Dupuytren's disease) into the base of your finger. So, if recurrence occurs on both sides of the graft but cannot bridge across the graft, the finger is less likely to form a contracture.
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It is a day surgery procedure under general anaesthetic.
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In this situation, therapy will be delayed two weeks until the grafts have healed.
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The skin graft is taken from the groin area and the skin closed with dissolving sutures and a waterproof dressing.
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You will be provided with a sling and instructed to keep your hand elevated (chest height) at all times for 2 weeks. If the hand is not elevated, fluid will rapidly collect under the graft and it will fail.
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If full-thickness skin grafting needed, this will be discussed prior to your operation.
Recovery
Recovery is similar to limited fasciectomy surgery except for the following:
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Due to the need for elevation while the graft heals, your first visit to the hand therapist will be at 2 weeks.
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Keep the hand immobilised for 2 weeks means that you will have more stiffness to begin.
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Due to the necessary delay in starting exercises, it is essential that you follow recommendations.
Full-thickness skin grafting
The importance of hand therapy
The importance of hand therapy in your recovery cannot be underestimated. Each person responds to surgery differently. Some people breeze through their recovery with minimal stiffness, others struggle to regain normal movement. Most people will have 6 sessions with the hand therapist. A good hand therapist can be very important in achieving a good outcome. Your progress will be carefully monitored by the surgeon and the hand therapist.
Hand therapy tools used for rehabilitation after Dupuytren's contracture treatment
(Left to right): Coban (controls swelling); neoprene sleeve (controls swelling & straightens the finger); Capener splint (straightens the finger); and thermoplastic night splint to straighten fingers.
What are the risks of Dupuytren's surgery?
Recurrence Despite surgery, the Dupuytren’s tissue can reappear in the same place (recurrence) or form in other parts of the hand (extension of the disease).
Delayed wound healing can occur where the diseased tissue has been removed and left a very thin area of skin.
Haematoma (collections of blood) can collect under the skin and may become infected.
Nerve or artery injury risk is less than 1% but there can be altered sensation in the finger for many months simply due to swelling of the nerve as a result of surgical dissection. The use of a tourniquet and 4X magnification minimises the risk of permanent injury. Nerve or artery injury is more likely in revision surgery due to extensive scar tissue.
Residual contracture after surgery is, to some degree, predictable based on the severity of the contracture. Full correction of the smaller (PIP and DIP) finger joint contractures is usually possible on the operating table. However, the tendon that straightens the joint may be stretched if the joint has been bent for many years. When the tendon is too lax to straighten the joint, there will usually be 35-40° residual contracture.
Stiffness affecting the ability to make a full fist is always a risk. This is more likely to occur in women. Many months of therapy and splinting may be required in such cases.
Carpal tunnel syndrome is a risk for any surgery of the hand or wrist. If you have signs and symptoms of carpal tunnel syndrome or imaging that suggests you have this condition, you may need to have a carpal tunnel release when your Dupuytren's surgery is performed. This will modify you rehabilitation program and slow your recovery. However, proceeding with surgery without carpal tunnel surgery is likely to end in a very poor outcome. Most people prefer to have both surgeries at the same time. An alternative is to do the carpal tunnel surgery first and delay the fasciectomy surgery.