Each patient should be assessed individually and the extent of the disability should be noted, especially how it affects normal day to day activity and work (1).
People who have static Dupuytren disease with minimal contractures and without significant loss of function will not require treatment and can be managed expectantly (1,2). Surgical intervention is considered in patients with significant functional disability (1).
Joint contractures become irreversible (when the ligaments remodel in the contracted position) in patients with longstanding deformity. This is especially seen in patients with proximal interphalangeal joint contracture and the patient should be referred to a specialist at the first sign of such contracture (1).
Conservative or non-operative management
- several non operative management methods such as radiotherapy, splinting, steroids, and topical vitamin A have been tried but data are lacking on the effectiveness of these methods (1)
- intralesional injections of gamma-interferon may help in reducing the size of the lesions
- injection of clostridial collagenase into the nodules and cords causing lysis and rupture of digital cords have been shown to be effective (3)
- showed early clinical promise for mild disease limited to the metacarpophalangeal joint (1)
- however, at the end of 2019 collagenase was withdrawn from the European market, having already been discontinued in Australia and Asia (5)
- reasons for this were commercial, not related to any safety or efficacy concerns
- needle fasciotomy (4)
- used in the elderly or frail (3)
- contractures in the palm or the fingers are divided using a blade or the bevel of a needle
- aim of procedure is to break the band or partially section it so the finger can be extended causing the fibrous band to snap (4)
- complications of the procedure include – skin breaks, localized pain, nerve and tendon injuries and infection (4)
Surgical management
- indications for surgical intervention include metacarpophalangeal joint contracture of 30°, any degree of proximal interphalangeal joint contracture (1) or if the deformity is progressive
- surgical option include
- limited fasciectomy – most popular technique, only the involved fascia is excised leaving the overlying skin.
- radical fasciectomy – extensive removal of all palmar fascia (3)
- dermofasciectomy – the diseased fascia and overlying skin are removed, skin grafts can be used to cover the wound (3)
- amputation – indicated in severe cases, those with delayed presentation, in recurrence or severe contractures affecting the little finger
- however, if the contraction is long-standing, there may be secondary changes in the interphalangeal joints preventing finger extension even after excision of the fibrosed tissue.
- in surgery of Dupuytren’s disease
- recurrence rates and prognosis in surgical management of Dupuytren’s generally vary depending on the extent of cord resection (5)
- needle fasciotomy
- highest recurrence rates 43% at three year follow-up, 85% at five year follow-up
- most patients recover quickly and are able to return to normal daily activity within 10 days of the procedure
- fasciectomy
- recurrence rate of 20.9% at five years
- most patients returning to work at four to six weeks
- dermofasciectomy
- recurrence rate of 8.4% at a mean follow-up of 5.8 years
- average time of return to work at 8.5 weeks
Restoration of painless hand function is encouraged by postoperative splintage and physiotherapy.
According to the British society for surgery of the hand recommendations, treatment of Dupuytren’s disease and contracture can be divided according to the severity of the disease
- mild
- moderate
- needle fasciotomy if appropriately trained; for metacarpophalangeal joint contractures
- possibly collagenase
- refer for surgery – limited fasciotomy
- severe
- refer for surgery
- limited fasciectomy
- dermofasciectomy (3)
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