7 Treatment Options for Dupuytren's Contracture

1
Observation

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Dupuytren's contracture is the curling of the fingers that occurs as a result of Dupuytren's disease, a problem with unregulated collagen formation in the palm of the hand and fingers. The excess collagen formation causes firm collections, called nodules, and string-like collections, called cords. It is these cords that pull the fingers down to the palm and prevent the complete straightening of the fingers.

The traditional "treatment" recommendation for people with this condition was to wait on Dupuytren's contracture as long as tolerable and only then have surgical treatment. This is what doctors call "watchful waiting." The reason to wait on surgical treatment was that Dupuytren's was never cured and repeat treatment was likely to be necessary at a later point. And, by waiting to treat the condition, the number of treatments needed throughout a patient's lifetime was kept to a minimum.

As some new treatments have offered a less-invasive way to manage Dupuytren's contracture, there are some doctors who now recommend early treatment. With collagenase injections and needle aponeurotomy, repeat treatment is not as much of a concern. Therefore, early treatment when the condition is less severe is becoming popular. And, by not waiting, the likelihood of fully correcting contractures is much better which, in turn, makes waiting on treatment much less popular.

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Stretching & Injections

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There used to be a time when physicians recommended stretching, splinting, and injecting cortisone into Dupuytren's tissue. In general, these treatments are, at best, only temporarily helpful and, at worst, they can actually make the condition progress more quickly. 

Cortisone injections are occasionally used to inject the nodular type of Dupuytren's (not the cords) and it can help to shrink down nodules. The downside is that these nodules typically return over time to their pre-injection size, so this treatment is rarely performed. In addition, there are possible side-effects of cortisone shots that may cause problems for some people.

Stretching and splinting were used more commonly in the past. The problem is that these treatments seem to be more likely to worsen the condition rather than help it. Many people will instinctively try to stretch the contracted finger, but in general this practice should be discouraged.

Stretching and splinting are sometimes used after treatment to increase joint mobility and prevent recurrence of the contracture. But, this is really only effective as a post-surgical or post-release treatment. At that time, stretching and splinting may commonly be recommended. Stretching as a treatment used on its own is generally not helpful.

3
Collagenase Injections

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Collagenase is an enzyme that is extracted from a bacteria. This enzyme is injected directly into a cord of Dupuytren's tissue and then allowed to break down the tight, contracted tissue. People who receive these injections will usually return to their doctor's office the following day, after the enzyme has had an opportunity to break down the tight tissue. At that point, your physician will manipulate the finger forcefully to fully break the contracted tissue.

Collagenase injections, sold under the trade name of Xiaflex, has become popular as it is relatively simple to perform and therefore many types of doctors now offer it. The procedure can be done entirely within a doctor's office, although it does require the person being injected to return on consecutive days.

The downside is that collagenase has fairly specific indications, meaning that it is not a useful treatment for everyone with Dupuytren's. Some doctors feel they can help patients more with a needle aponeurotomy or surgery, which are generally more versatile procedures. In addition, there is a high cost of collagenase and many insurance plans will not cover the medication.

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Needle Aponeurotomy

John Mahoney, M.D.

Needle aponeurotomy is a minimally invasive procedure that instead of removing the contracted Dupuytren's tissue, it uses the point of a needle to sever the cords and relieve contractures. Your doctor makes small punctures in the skin, no incisions, and by manipulating the tip of the needle, cuts through the contracted tissue in several locations.

The proponents of this procedure tout several benefits:

  • It is very safe. Complications can occur, but serious complications are unusual.
  • It is inexpensive. Compared to other treatments, needle aponeurotomy generally costs much less than collagenase or surgery.
  • It is easy. This is comparative, meaning that it may not be simple for everyone, but it can usually be performed in less than an hour and follow-up is seldom necessary.

There are possible downsides to needle aponeurotomy. Not everyone has a type of Dupuytren's that will be effectively treated with the needle procedure. Furthermore, recurrence of the condition can be common. And while repeating the procedure is generally not a problem, the recurrence tends to occur more quickly after the needle procedure compared to surgical treatment.

5
Surgery

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Surgery has long been the most common form of treatment for Dupuytren's contracture. There are many variations to how surgery can be done and how extensive it needs to be. When surgery is performed, an incision is typically made directly on top of the area of Dupuytren's, the abnormal tissue is removed, and the incisions are sutured closed.

The advantage of surgical treatment is that, even in the most advanced stages of Dupuytren's, there is usually something that can be done from a surgical standpoint. More extensive Dupuytren's may require a more extensive surgery, but it almost always can be addressed through an incision.

In addition, while all of these procedures address the contracted tissue of Dupuytren's, none of them cure the underlying condition called Dupuyren's disease. Therefore, recurrence of the contracture is always a possibility, no matter what treatment is performed. The average time between treatment and recurrence is the longest (meaning people don't need repeat treatment for the most amount of time) with surgery compared to injections or the needle procedure.

The major downside of surgery is that the recovery from the procedure can involve discomfort and can be prolonged. People may have bandages on for weeks and splints for months. There is often physical therapy involved in the treatment. Compared to the collagenase or needle procedure, the recovery from surgery is much more involved. The trade off is that your surgeon may be able to address more surgically than through those less invasive options.

6
Revision Surgery

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As mentioned earlier, one of the major problems with the treatment of Dupuytren's contracture is that the underlying problem is unchanged. Dupuytren's disease is the condition that causes the collagen in your body to be poorly regulated. People with this condition make too much collagen and don't break down old collagen very well. The treatments described here are all a treatment of the symptom of this problem—they don't address the underlying condition.

Someday, we expect that we will be able to offer a medication to people with Dupuytren's to prevent progression or recurrence of the contractures. However, until that time, we are stuck with treatments for the symptoms of Dupuytren's disease only. For that reason, Dupuytren's can, and almost always will, eventually come back. In those cases, further treatment can be considered. 

Repeat surgery can be tricky and definitely not as straight forward as initial surgery for Dupuytren's. Because of scar tissue formation, the normal anatomy and tissue planes within the hand become distorted, making revision (repeat) surgery much more prone to complication. In fact, some studies have shown a complication rate up to 10 times higher in revision surgery situations.

7
Salvage Treatments

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There are times when treatments don't work as well as hoped or when Dupuytren's advances despite treatment. In some people, the contracture of the fingers has progressed to a degree that is no longer fixable, even with aggressive treatments. In these situations, a salvage procedure may be necessary.

A salvage procedure is a treatment that is not used to fix a problem, but rather to make the situation as tolerable as possible. Some of the salvage procedures rarely performed in the treatment of Dupuytren's contracture include:

  • Joint fusion: A joint fusion is a surgery to permanently set a joint in a position and have bone grow across it so that it will never bend again. When the joint is fused, it will no longer contract, even if the Dupuytren's progresses.
  • External fixation: An external fixator is a device attached to the bone that can stretch soft-tissues around the joint over long time periods. In people with very contracted tissues, stretching for weeks or months may help.
  • Amputation: Amputation of a finger is rarely performed in Dupuytren's, but it can be helpful in the most challenging situations. Particularly in small fingers—and in people with significant limitations in the functions of the hand—removal of a digit can be helpful in some rare situations.

Again, salvage treatments are reserved for the most severe situations that have typically failed more traditional treatments. However, there are possible steps to take in these difficult circumstances.

Sources:

Becker GW, Davis TR: The outcome of surgical treatments for primary Dupuytren's disease: A systematic reviewJ Hand Surg Eur Vol 2010;35(8):623-626.

Black EM, Blazar PE. "Dupuytren disease: an evolving understanding of an age-old disease" J Am Acad Orthop Surg. 2011 Dec;19(12):746-57.

Denkler K: Surgical complications associated with fasciectomy for Dupuytren's disease: A 20-year review of the English literature. Eplasty 2010;10: e15.

Hindocha S, Stanley JK, Watson S, Bayat A: Dupuytren's diathesis revisited: Evaluation of prognostic indicators for risk of disease recurrenceJ Hand Surg Am 2006;31(10):1626-1634.

Hurst LC, Badalamente MA, Hentz VR, et al: CORD I Study Group: Injectable collagenase Clostridium histolyticum for Dupuytren's contractureN Engl J Med 2009;361(10):968-979.

Van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM: A comparison of the direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren's disease: A 6-week follow-up studyJ Hand Surg Am 2006;31(5):717-725.

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