Dupuytren’s disease is a benign fibroproliferative disorder that occurs in the palmar fascia leading to nodules, cords, and contractures of the fingers. There is no proven correlation with vibration tools or other manual work in development of Dupuytren’s disease, although there are theories that a microtrauma mechanism may act to direct myofibroblast contracture. The link between alcohol intake and Dupuytren’s disease has been questioned over the years. A review by Hindocha et al1 concluded that alcohol excess is associated with the disease that is more likely to require surgical correction than conservative management, although the mechanism for this is unclear. A previous study by this group has shown that excess alcohol intake was associated with an increased severity of the disease.2 The inheritance of Dupuytren’s disease is thought to be autosomal dominant (not recessive) with variable penetrance. As better epidemiological data emerge, it is recognized that white men of Northern European descent are most commonly affected. The disease is also regularly encountered in women and in other ethnic groups such as Japanese individuals. There appears to be both a genetic and environmental influence on the condition. The ring and little fingers (not the middle and ring) are most commonly affected, followed by the middle finger. The thumb and index finger can be affected, but this is less common.
father and grandfather had similar problems, and he would like to discuss treatment options with you. Which The presence of multiple Dupuytren’s diathesis factors in a patient such as this man increases the risk of recurrent disease by up to approximately 70%, compared with a baseline recurrence risk of 20–25% in patients without diathesis factors.1 The initial description of Dupuytren’s diathesis by Hueston included four factors2: 1. Ethnicity 2. Family history 3. Bilateral disease 4. Ectopic lesions (outside the palm) The scenario gives only two of these factors. He may develop ectopic disease, such as dorsal knuckle pads (Garrod’s pads) and may also be affected by plantar or penile fibromatosis. Subsequent to Hueston’s description, additional items have been added by Hindocha et al1 who suggested two new factors: male sex and age at onset less than 50 years (for which this patient meets both criteria). These authors also proposed that the family history should include one or more affected siblings/parents and that only ectopic lesions in the knuckles (Garrod’s pads) should count. Finally, because inheritance is autosomal dominant, any of his siblings including sisters are also at risk, although penetrance of the phenotype is variable.
Dupuytren’s disease affects much of the palmar fascia, but Cleland’s ligaments are usually spared in this condition. These fascial bands pass dorsal to the neurovascular bundles in the fingers from the periosteum and flexor tendon sheath to the lateral skin. Grayson’s ligament passes transversely from the volar aspect of the flexor tendon sheath to the skin. It prevents bowstringing of the neurovascular bundle during digital flexion. In Dupuytren’s disease Grayson’s ligament is often tightly adherent to the bundle, making dissection more challenging. The natatory ligaments are found just deep to the skin, extending transversely between the web spaces and, when involved in Dupuytren’s disease, may restrict both metacarpophalangeal (MCP) joint abduction and proximal interphalangeal (PIP) joint extension. The lateral digital sheet is located lateral to the neurovascular bundles within the digit and, when involved in Dupuytren’s disease, can restrict proximal interphalangeal (PIP) and distal interphalangeal (DIP) joint function.1–3
The presence of a spiral cord can complicate the surgical management of Dupuytren’s disease, as the pliable neurovascular bundle can become distorted around the shortened fibrous structures, spiraling around the disease as it tightens up. Great care must therefore be taken when dissecting the Dupuytren’s disease from the neurovascular bundle in the presence of a spiral cord, as the abnormal anatomy risks iatrogenic damage to the nerve and vessel which may be displaced to or beyond the midline of the digit. Spiral cords may cause flexion contractures of the PIP joint. The common components of a spiral cord are: • Lateral digital sheet • Pretendinous band • Spiral band • Grayson’s ligament • Natatory ligaments (included by many, but not all, authors) Landsmeer’s ligament is not part of the spiral cord. It is also known as the oblique retinacular ligament and originates on the volar aspect of the middle phalanx and inserts on the dorsal aspect of the distal phalanx. It helps coordinate PIP joint and DIP joint motion.1–3
Established flexion contractures of the PIP joint are the most difficult to correct because the volar structures shorten when the joint is left in flexion for a prolonged time. The MCP joint is far more forgiving, as the collateral ligaments are taut when the joint is flexed (i.e., the “safe” position for splinting). MCP joint contractures greater than 30 degrees and any PIP joint contracture are commonly quoted as indications for surgery, although lesser contractures of the MCP joint may be sufficiently troubling to warrant treatment, so the decision is tailored to the individual. Garrod’s pads are rarely an indication for surgery but may be so if they are symptomatic. A positive Hueston’s test is where the hand cannot be placed flat on a tabletop and may be an indication for surgery if there are associated functional problems.1–4
Collagenase injection for the treatment of Dupuytren’s disease has more recently become popular. The treatment involves injecting collagenase into a palpable cord and then allowing it to weaken before physically breaking the cord by external manipulation 24–48 hours later. Initial recommendations were that one cord should be treated at a time, but this has been relaxed and it is considered appropriate to treat the two cords simultaneously. Two office visits remain the minimum per cord, assuming that one injection and one manipulation is sufficient. Some cords require more than one injection/manipulation cycle. Recurrence is dependent on which joint is affected as well as by other factors including disease severity. At 5 years posttreatment, significant recurrence at the MCP joint is reported to be around 20–40%, while this is increased to 60–70% at the PIP joint.1–3 Collagenase treatment does not obviate any risk of a wound, as skin tears can commonly occur with postinjection manipulation. Therefore, all patients must be warned about wounds due to skin tears developing. These do tend to heal quickly with nonsurgical management and are not usually of great concern. The collagenase used in Dupuytren’s contracture is a blend of two clostridial collagenases, AUX I and AUX II, from Clostridium histolyticum (not Streptococcus). Streptococcus pyogenes, Staphylococcus aureus, and Clostridium perfringens all produce hyaluronidase (rather than collagenase) as a mechanism of penetrating soft tissues. Methods of producing hyaluronidase (Hyalase) have led to its use in local anesthesia and correction of hyaluronic acid facial fillers. All patients will have developed antibodies to the injection by their second injection, but this has not been associated with any adverse outcomes. Subsequent tendon rupture is extremely rare, with three reports in 2,600 injections performed within the Collagenase Option for Reduction of Dupuytren’s (CORD’s) clinical trials.1–4
Following a severe, prolonged contracture, the neurovascular bundles may be restricted and unable to tolerate full extension of the digit. The risk of vascular compromise is also increased in revision surgery. Although aggressive release of a contracted PIP joint capsule may give improved correction of the finger intraoperatively, this may be at the expense of joint stability, or result in a loss of flexion if care is not taken. Loss of flexion may be more troublesome than loss of extension for most functional activities. Many surgeons advocate careful serial release of the accessory collateral ligaments and volar plate to improve correction, but many would advise against a forced capsulotomy. The reported outcomes are mixed, with some series demonstrating greater early loss of correction with joint release, but comparable outcomes to fasciectomy alone in the longer term.1,2 A lazy-S incision is not recommended as it is difficult to deal with a skin deficit using local flaps with this incision pattern. Problems with the MCP joint volar plate or ligaments would be highly unusual. A boutonniere deformity indicates central slip attenuation, and a PIP joint correction is unlikely to be maintained without this being addressed.
joints have contractures of 45 degrees and the ring finger PIP joint has a contracture of 20 degrees. There are fasciectomy. There are variable recurrence rates reported worldwide following treatment of Dupuytren’s disease, and confusion arises because there is debate about whether any recurrence of disease is included in outcome figures, or whether only recurrent disease requiring further treatment should be included.1,2 Despite these variations, it is generally accepted that needle fasciotomy shows earlier recurrence than fasciectomy. However, the trade-off of greater downtime after fasciectomy means that many surgeons and patients find needle fasciotomy preferable. Some surgeons do report comparable outcome figures with extensive needle fasciotomy. Reported recurrence rates after limited fasciectomy are in the order of 21% at 5 years, compared with 85% for needle fasciotomy.3 Dermofasciectomy is usually reserved for cases with extensive skin involvement or for aggressive or recurrent disease. It is most often required over the proximal phalanx. Wounds are closed with skin grafts or left to heal by secondary intention. Radical fasciotomy involves extensive resection of volar and digital fascia including diseased and nondiseased tissue. It does not decrease the recurrence rate and carries higher rates of complication than limited fasciectomy. In this scenario, the PIP joint contractures are mild, and a full correction is likely whichever technique is performed.
When undertaking a fasciectomy for Dupuytren’s disease, dissection should start in the palm to safely identify the neurovascular bundles. Skin flaps are elevated to expose the normal and abnormal palmar fascia. In the palm the nerves and vessels will be deep to this fascia and, once identified, they can be traced distally under direct vision. As dissection proceeds distally into the digits, the course of the nerves and vessels may be abnormal with them encased in and distorted by disease. The risk of iatrogenic damage is minimized using this approach. When designing skin flaps in the palm and digits, a balance must be made between narrow bases that reduce flap vascularity and wide bases that do not transpose well. Z-plasties in the palm need to be small, as there is little movement here, whereas larger Z-plasty flaps can work over the proximal phalanx. Skin flap thickness is carefully judged to minimize residual disease attached to skin while maintaining vascularity. Where there is obvious involvement of disease with the overlying skin, dermofasciectomy should be performed. Only diseased fascia needs to be removed, as there is no benefit in radical fasciectomy, which is now only of historical interest. Complete wound closure on the palm is not necessary and in fact, leaving areas to heal by secondary intent works very well. Grafts may, however, be preferred in larger defects in the digits. Tourniquet release (if used) before wound closure allows assessment of digit vascularity and hemostasis, and reduces the risk of hematoma. Vascularity of each digit must always be checked and if the finger is white secondary to tension on the contracted digital vessels, then splinting the finger in the least amount of flexion that allows it to be pink is advocated. In clinic, extension can be progressively increased over 1–2 weeks.1,2
The patient in this scenario is displaying signs of a Dupuytren’s flare, which is sudden-onset development of swelling, redness, and stiffness to the operated hand similar to, or a subtype of, complex regional pain syndrome. This tends to occur toward the end of the first month following surgery after an apparently normal early healing response. At week 3 or 4 postsurgery, there is typically a deterioration in rehabilitation progression and function which may be linked in some way to therapy and splinting regimens. The key steps to take are early and frequent hand therapy (not immobilization, which will lead to additional stiffness), together with methylprednisolone (Medrol) and gabapentin (Neurontin). Regular nonsteroidal medications may also be useful where not contraindicated. Sympathetic blockade (stellate ganglion block) may be helpful, rather than a regional nerve anesthetic block. Antibiotics are indicated only in cases where there is evidence of active infection with wound healing issues or erythema and cellulitis. Likewise, a return to theater would only be indicated in this scenario if underlying infection with an abscess requiring drainage was suspected.1,2