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Dupuytren’s Contracture

What is Dupuytren’s Contracture?

Dupuytren’s Contracture is a progressive disease of the hand that causes the fingers to flex toward the palm, making it difficult or even impossible to straighten the fingers. The palm contains a fibrous layer of tissue that lies just beneath the skin called the palmar fascia. For reasons not fully understood, this fascia can thicken, causing it to contract and create flexion tethers on the metacarpophalangeal (MCP) joints and/or the proximal interphalangeal (PIP) joints. The MCP joints are located at the base of the fingers where the fingers attach to the hand, and the PIP joints are the next knuckle up on the fingers as you move away from the palm. The dotted lines in Figure 1 show the thickened cords present in Dupuytren’s contracture. You may also notice the nodules present at the PIP joints of the long, ring, and small fingers.

Figure 1

Figure 1

Dupuytren’s contracture tends to be hereditary, more commonly found in men older than 50 years, and especially in people of northern European descent, although it is also seen in women and younger patients. Injury to, or surgery on the hand may also stimulate the development of Dupuytren’s contracture.

Signs and Symptoms:

Dupuytren’s contracture is characterized by the formation of palpable nodules on the palm and small, cord-like structures extending from the palm up into the fingers (Figure 2). These nodules may be mildly painful in their early development. Dupuytren’s contracture most commonly affects the ring and small fingers, followed by the middle finger then thumb. The index finger is rarely affected. Patients may also notice they are unable to lay the palm-side of the hand completely flat on a tabletop.

Figure 2

Figure 2

Non-surgical Options:

Presently there is not a cure for Dupuytren’s Contractures. This condition was first treated by surgical fasciectomy, removal of the constricted bands in the palms of the hand, by Baron Guillaume Dupuytren in 1831. While surgery is certainly appropriate in certain Dupuytren’s cases, today there are additional treatment options.

Newer developments in treatment provide some non-surgical alternatives with very promising results. These include an injectable enzyme called XIAFLEX or Enzymatic Fasciectomy with Collagenase, and the needle-puncturing technique known as Percutaneous Aponeurotomy. Both treatments work to release the main cords that create flexion tethers in the MCP joints or the PIP joints. However, these treatments are not directed at completely relieving all fascial contractures, or removing all cords/nodules.

The benefits of these treatment options are:

Xiaflex_logoShort duration of procedure — functioning hand in minutes.
Minimally invasive office procedure – no scalpel, no hospital.
Rapid Recovery – quick recovery to normal activities.
Few Complications – minimal risks compared to surgery (can have similar complications such as nerve, vessel, and tendon injury although rare).
Minimal cost – less expensive than surgery (ask about the Copay Savings Program).

XIAFLEX Injection: Collagenase is an enzyme derived from the bacterium Clostridium histolyticum that hydrolyzes the collagen cords, causing the cords to cleave into fragments and rapidly dissolve/degrade. XIAFLEX is currently the only FDA-approved collagenase on the market. During treatment with XIAFLEX, collagenase is injected directly into the cords that cause the fingers to bend. Figure 3 below shows a hand prior to collagenase injection, and Figure 4 shows the hand 4 weeks after the injection.

Figure 3: Before XIAFLEX injection

Figure 3: Before XIAFLEX injection

Figure 4: Four Weeks after XIAFLEX injection

Figure 4: Four Weeks after XIAFLEX injection

Day of Injection (at clinic):

  • Multiple injections will be made directly into the Dupuytren’s cords in the hand.
  • Injections will be done without anesthesia to reduce chance of injecting XIAFLEX into nerves found very close to the Dupuytren’s cords.
  • A compressive dressing is then placed, and ice is applied.
  • Most patients tolerate the injections well. (Patients that will not tolerate injections without local anesthesia may not be good candidates for this procedure and may require open fasciectomy surgery.)
  • Expect some swelling, bruising, and soreness for several days.Plan “RICE”: rest, ice, compression, and elevation.
  • Do not attempt to straighten fingers before scheduled appointment with physician.
  • Take pain medication if needed and as prescribed. Call if any problems or questions arise.

24-48 Hours Post Injection (at clinic):

  • Return to clinic for gentle manipulation of fingers to release cords.
  • Your palm will be prepped with betadine and a local anesthetic will be injected before manipulation.
  • A gentle force is then applied to extend affected fingers.
  • An audible and palpable popping occurs as the cords are released and extension improves.
  • Continue to elevate, ice, and take pain medication if needed and as prescribed

Following Manipulation (at therapy):

  • Expect your first therapy appointment the same or next day following manipulation at clinic.
  • Receive extension splint from therapist for involved fingers to wear for 6-8 weeks at night. (A forearm-based splint with wrist and fingers in extension may be necessary for patients with severe contractures.)
  • Begin slow progressive stretching and range of motion exercises daily. (You may still feel cords pop or tear while working on range of motion.)
  • Continue with therapy 1-2 times a week for approximately 6 weeks (often performed as home program).
  • Again, expect some swelling and bruising in the digit/palm.

3-4 Weeks Post Injection (at clinic):

  • Follow up appointment in clinic with P.A. or M.D. to address activity level and continued rehab.
  • Continue gentle stretching and range of motion exercises as advised.
  • Continue to wear extension splint at night until 6-8 weeks after injection.

6-8 Weeks Post Injection:

  • May discontinue extension splint at night.
  • Continue gentle stretching and range of motion exercises as advised.

Considerations:

  • Occasionally, reinjection may be considered if necessary to achieve further extension. (It is possible for a patient to receive up to three injections at thirty day intervals.)
  • If joint contracture is present after rupture of cord(s), surgical joint release (or capsulectomy) may be required.

Recent studies by Starkweather et al., Badalamente et al., and Hurst et al. published in the New England Journal of Medicine showed range of motion improvement on an average of 41 degrees for MCP joints and 29 degrees for PIP joints with an overall clinical improvement in 94% of MCP joints and 67% of PIP joints. In a 3-year follow-up study by Peimer et al. on Dupuytren Contracture recurrence following treatment with XIAFLEX, the data showed the recurrence rate after XIAFLEX injection to be comparable to other standard treatments such as surgical fasciectomy indicating that XIAFLEX is an effective and safe treatment for Dupuytren’s contracture.

The most common complications of collagenase injections are mild edema, swelling and/or bruising at the injection site. Sometimes, the skin may become irritated and itchy, or the skin may fissure or tear during manipulation. Nerve injury and flexor tendon ruptures have also been reported but are rare. Most of these complications are self-limiting side effects and should resolve within 21 days.

protocol

Percutaneous Aponeurotomy: Percutaneous Aponeurotomy was first proposed by a French Rheumatologist, Debeyre, with recent studies showing success with this technique. This treatment option is most effective for joints with smaller contractures. Indications are very similar to the collagenase use and results are very similar as well.

This procedure is performed in the doctor’s office. After a local anesthetic is injected in the hand, a small needle is used to pass through the cords at multiple levels. The finger is then passively extended with gentle tension on the cords until they rupture. Occasionally, this procedure is used in conjunction with the collagenase during the manipulation period to release additional tether. Many studies have reported considerable reduction in flexion contracture using this technique. Patient pain scores and satisfaction with hand function are reportedly better for this group at 6 weeks than those with surgical fasciectomy.

The most common complications reported are skin fissures and transient nerve paresthesias. Nerve injury and flexor tendon ruptures have also been reported but are rare.

Surgical Options:

Surgical Fasciectomy: Surgery may be recommended if conservative treatment is not effective or if a patient presents with multiple contractures, or more moderate to severe contractures. The goals of surgical fasciectomy are to remove the cords and to restore range of motion. Although very effective, surgical fasciectomy is a fairly large undertaking, often requiring a prolonged rehab course with extensive limitation of activities and time off from work. If surgery is the appropriate treatment for you, the surgeon will most likely use a zigzag type of incision to allow for better healing and motion of the fingers. Also, if there is a PIP joint contracture, a capsulectomy (or joint release) may be necessary. Part of the incision may be left open to help with drainage.

Following Surgery:

  • Expect a surgical bulky dressing and extension splint to be kept in place for 3-5 days.
  • Elevate and ice for at least 3 days.
  • Continue to elevate as often as possible until your next clinic visit. (Elevate above your heart.)
  • Shower with a plastic bag covering the splint and seal with tape.
  • Take your pain medicine as needed and as prescribed. Call if any problems or questions arise.

3-5 Days Post Op (at therapy):

  • Your therapist will assist you with first dressing change and will show you how to do subsequent dressing changes.
  • Therapist will make an extension splint for immobilization between exercises and at night.
  • Therapist will address wound care, stretching, active and passive range of motion (ROM) exercises, scar management, edema control, and strengthening as appropriate (usually 2-3 visits per week).

10-14 Days Post Op (at clinic):

  • Follow up appointment in clinic with P.A. or M.D.
  • Sutures will be removed.
  • Continue to attend therapy and do home exercise program.

3-6 Weeks Post Op:

  • Functional daily use of hand permitted as able.

6-8 Weeks Post Op (at clinic):

  • Follow up appointment in clinic with M.D.
  • Depending on the extent of the incision, wound should be healed.

3-6 Months Post Op:

  • Continue to wear splint at night to maintain extension (if indicated by M.D.).
  • Gradual return to normal activities.

Overall, the above options do not provide a cure for Dupuytren’s. However these options can help release contracture and greatly improve hand function. Enzymatic fasciectomy with collagenase (XIAFLEX) and percutaneous aponeurotomy are effective short-term treatments for patients with mild to moderate Dupuytren’s disease. Long term recurrence rates after collagenase injection or percutaneous aponeurotomy are unknown, but early results appear promising. Surgical Fascietomy is highly effective for moderate to severe contractures, but requires a strenuous rehabilitation program for best results. Consult your physician to see which treatment option is best for you.

protocol

Note: These instructions are to serve as guidelines and are subject to Physician discretion. Actual progress may be faster or slower depending on the individual.

References:
Starkweather KD, Lattuga S, Hurst LC. Badalament MS, Guilak F, Sampson SP, et al. Collagenase in the treatment of Dupuytren’s disease: an in vitro study. J Hand Surg 1996; 21A:490-495.

Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan TD, Meals RA, et al. Injectable collagenase Clostridium histolyticum for Dupuytren’s contracture. N Engl J Med 2009; 361:968-979.

Srinivasan RC, Shah AS, and Jepson PJ. New Treatment Options for Dupuytren’s Surgery: Collagenase and Percutaneous Aponeurotomy. J Hand Surg 2010; 35A:1362-1364.

Peimer CA, Blazar P, Coleman S, Kaplan TD, Smith T, Tursi JP, et al. Dupuytren Contracture Recurrence Following Treatment with Collagenase Clostridium Histolyticum (CORDLESSS Study): 3-Year Data. J Hand Surg 2013; 38A:12-22