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Dupuytren’s Disease

What is Dupuytrens Disease?

Dupuytren’s disease is a condition in which there is thickening and shortening of the deep tissue (fascia) which passes from the palm of the hand into the fingers. It often starts with a lump (called a nodule) beneath the skin in the palm near the base of the ring or little finger that is usually painless but can be tender to direct pressure. It can develop over months or years causing these fingers to be pulled down into the palm and leading to the inability to straighten these fingers, (called Dupuytren’s contracture). This can cause problems with activities such as holding small tools, holding a ball (e.g. for bowling), getting your hand into small places (e.g. putting it in your pocket or putting gloves on), and shaking hands. Whilst the disease usually affects just the ring and little fingers, in severe cases all the fingers and the thumb can be affected. Both hands are usually affected although one may be much worse than the other.

What is the cause?

Dupuytren’s Diseases is a common condition. In many people Dupuytren’s is genetically linked – you are born with an inherited tendency to develop it. There are other factors that can increase the risk of developing the condition, trigger its onset, or make it worse. These include excess alcohol, diabetes, epilepsy (possibly due to anti-epileptic medication), smoking and trauma (such as a broken wrist). Dupuytren’s is not thought to be the result of chronic heavy manual work. The condition tends to arise in middle age, although its progression tends to be more severe if it is developed at a young age.

Diagnosis

The diagnosis can often be made from the clinical history (the account of events and symptoms from the patient) and the clinical examination. There is usually no need for any special tests.

Treatment Options

Many people with mild Dupuytren’s disease require no treatment. Possible treatments include:

1. Cortisone injection

painful lumps/nodules in the palm can be treated with a steroid injection into the lump itself. For 50% of patients it is successful in softening and flattening the lump. Several injections may be necessary and the injection itself is uncomfortable.

2. Radiotherapy

Can be used to slow the disease process down or even improve symptoms in some cases. It can also be used if the Dupuytren’s recurs quickly after surgery. It does however require multiple visits (for example 7 treatments on a daily/alternate day basis) to a radiotherapy centre such as in Poole. There are associated risks such as redness of the skin and superficial skin loss. Radiotherapy is infrequently used in the UK.

3. Collagenase injection – Xiapex

This is a new technique that involves an injection into the thickened tissue to “dissolve” a short portion of it, and improve the contracture. It does not actually remove the tissue but does improve hand function by virtue of improving the straightness of the fingers. This is performed as an outpatient procedure.

4. Percutaneous Fasciotomy/ Needle Aponeurectomy

This minimally invasive procedure is performed under local anaesthetic in patients with very well defined cords of disease in the palm. A needle or small blade is used to weaken the cords, allowing the fingers to be straightened. As the tissue isn't removed the rate of recurrence is higher than other forms of treatment, however the recovery period is much shorter and less complicated. . This is performed as an outpatient procedure.

5. Open Fasciectomy

This is the mainstay of treatment for Dupuytren's disease. It involves removing the diseased tissue from the hand and fingers through a series of zigzag incisions. This procedure allows for better straightening of the fingers, especially in long standing cases of deformity. This is the most commonly performed surgical procedure for Dupuytrens contracture. This is usually undertaken as a day case procedure.

6. Dermofasciectomy

Dupuytren’s tissue and the overlying skin from the palmar surface of the finger are removed and replaced with a skin graft which is usually taken from the inner arm. This procedure is more major, but has been shown to give a more complete and sustained correction of finger deformities than simple fasciectomy. It is usually used in treating recurrent disease or in younger patients. The recovery time for this is longer than other treatments. This type of surgery is usually undertaken as a day case procedure.

Surgery

Surgery is usually recommended when there is a bend or contracture of 30 degrees or more at the knuckle or any contracture of the small finger joints. Surgery is rarely recommended for Dupuytren’s affecting the palm alone with no finger contracture. The aim of surgery is to straighten the fingers and improve hand function. Dupuytren’s has no medical cure and surgery cannot eradicate it. The potential for recurrence is with the sufferer for the rest of their life. The rate of progression is an important factor in determining which treatment option is recommended and when it is undertaken.

Wound Care:

At surgery a large dressing will be applied, which may include a plaster cast in some cases. This will remain on until your first review in outpatients. This will be between 48 hours and 10 days depending upon the exact nature of your surgery.

Most patients can expect to stay in hospital for 4-8 hours.

You should keep your hand/arm elevated whenever possible over the first week after surgery. While sitting this is best achieved by placing your arm on pillows above the level of your heart

You will be referred to a Hand Therapist for advice on hand exercises and management of the swelling and scarring. For deformity of the fingers a plastic “night splint” is recommended for 3 months after surgery. The Hand Therapist will fabricate this for you.

Post-surgery hand therapy is vital in order to achieve the best result and in some cases can require prolonged treatment.

How long will it take to recover?

Recovery depends on the type of surgery that you have.

1. Percutaneous fasciotomy or Collagenase

you will be using your hand for light activities within a few days.

2. Fasciectomy

sutures are removed after 12-14 days. A dressing is in place until the incision is fully healed, usually 2-3 weeks. It is usually 6 weeks before the majority of use returns to the hand.

3. Dermofasciectomy and skin graft

this is a more major procedure. Dressings are usually required for 3-4 weeks and movement takes longer to return. The major benefit however is the low recurrence rick. This is approximately 10% or 1 in 10 at 5 years.

Driving

You should not drive for at least 2 weeks following your operation. The exact timing or your return will depend upon the type of operation performed You need to be able to perform an emergency stop safely and use the gear stick, steering wheel and hand brake without difficulty. After percutaneous aponeurectomy or collagenase (Xiapex), you may be able to return to driving sooner and you surgeon will give you advice on this.

Work:

Returning to work will depend upon the exact procedure performed, your circumstances and type of work. Your surgeon will give you detailed advice on this.

What are the potential complications?

The majority of patients are very satisfied with the outcome of surgery. Whilst uncommon, all surgical procedures are associated with some risks. Every effort is made to minimize these to ensure the best possible outcome from your surgery.

Infection - Uncommon occurs in approximately 5% of operations and usually treated very successfully with antibiotics. Very rarely would require further surgery.

Painful/Tender/thickened Scars - the vast majority of patients complain of some discomfort around the scar but it generally resolves with time. Wound care and desensitization as directed by your physiotherapist/hand therapist will improve this.

Incomplete correction - it is more likely that you will not be able to straighten the finger fully if it has been bent for a long time, or bent at the small finger joints as well as the knuckle joint.

Recurrence of Dupuytren’s in the operated finger or in other parts off the hand.

Prolonged healing - occasionally several weeks of dressings are required.

Skin graft failure following a dermofasciectomy.

Haematoma or severe bruising.

Nerve damage can occur during surgery, this can leave you with a temporary “fuzzy feeling” or permanent loss of feeling in the finger. This is more common in re-do or revision surgery.

Cold intolerance can occur leading to severe pain in finger in cold weather.

Blood vessel injury.

Finger stiffness with limitation of bending of the involved finger.

CRPS – complex regional pain syndrome, this is an uncommon but serious complication. It can on rare occasions leave you with a less functional hand with on-going pain, stiffness and swelling. See section on CRPS. The exact incidence or rate of CRPS after surgery is unknown. It probably occurs in a significant form in approximately 1-2% of cases

Amputation - this is a rare occurrence. It can become necessary if blood vessels a severely damaged or if no useful function can be retained in the finger. It is more likely in re-do or revision surgery

See also BSSH guidelines

www.bssh.ac.uk/education/guidelines/dd_guidelines.pdf