Dupuytren’s disease: How to recognize its early signs

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Applied Evidence

Dupuytren’s disease: How to recognize its early signs

J Fam Pract. 2017 March;66(3):E5-E10

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References

1. DiBenedetti DB, Nguyen D, Zografos L, et al. Prevalence, incidence, and treatments of Dupuytren’s disease in the United States: results from a population-based study. Hand. 2011;6:149-158.

2. Townley WA, Baker R, Sheppard N, et al. Dupuytren’s contracture unfolded. BMJ. 2006;332:397-400.

3. Rayan GM. Clinical presentation and types of Dupuytren’s disease. Hand Clin. 1999;15:87-96.

4. Hindocha S, Stanley JK, Watson S, et al. Dupuytren’s diathesis revisited: Evaluation of prognostic indicators for risk of disease recurrence. J Hand Surg Am. 2006;31:1626-1634.

5. Bayat A, McGrouther DA. Management of Dupuytren’s disease—clear advice for an elusive condition. Ann R Coll Surg Engl. 2006;88:3-8.

6. Gudmundsson KG, Arngrimsson R, Sigfússon M, et al. Epidemiology of Dupuytren’s disease: clinical, serological, and social assessment. The Reykjavik Study. J Clin Epidemiol. 2000;53:291-296.

7. Wilbrand S, Ekbom A, Gerdin B. The sex ratio and rate of reoperation for Dupuytren’s contracture in men and women. J Hand Surg Br. 1999;24:456-459.

8. Noble J, Arafa M, Royle SG, et al. The association between alcohol, hepatic pathology and Dupuytren’s disease. J Hand Surg Br. 1992;17:71–74.

9. Mikkelsen OA. Dupuytren’s disease—initial symptoms, age of onset and spontaneous course. Hand. 1977;9:11-15.

10. Arkkila PE, Kantola IM, Viikari JS. Dupuytren’s disease: association with chronic diabetic complications. J Rheumatol. 1997;24:153-159.

11. Liss GM, Stock SR. Can Dupuytren’s contracture be work related? review of the evidence. Am J Ind Med. 1996;29:521-532.

12. Geoghegan JM, Forbes J, Clark DI, et al. Dupuytren’s disease risk factors. J Hand Surg Br. 2004;29:423-426.

13. Smith SP, Devaraj VS, Bunker TD. The association between frozen shoulder and Dupuytren’s disease. J Shoulder Elbow Surg. 2001;10:149-151.

14. Nunn AC, Schreuder FB. Dupuytren’s contracture: emerging insight into a Viking disease. J Hand Surg. 2014;19:481-490.

15. Arafa M, Steingold R F, Noble J. The incidence of Dupuytren’s disease in patients with rheumatoid arthritis. J Hand Surg Br. 1984;9:165-166.

16. Hueston J. Lessons in Dupuytren’s disease. Ann Chir Main Memb Super. 1992;11:349-354.

17. Tubiana R. Prognosis and treatment of Dupuytren’s contracture. J Bone and Joint Surg AM. 1955;37:1155-1168.

18. Howard JC, Varallo VM, Ross DC, et al. Elevated levels of ß-catenin and fibronectin in three-dimensional collagen cultures of Dupuytren’s disease cells are regulated by tension in vitro. BMC Musculoskelet Disord. 2003;4:16.

19. Ketchum LD, Donahue TK. The injection of nodules of Dupuytren’s disease with triamcinolone acetonide. J Hand Surg Am. 2000;25:1157-1162.

20. Betz N, Ott OJ, Adamietz B, et al. Radiotherapy in early-stage Dupuytren’s contracture. Long-term results after 13 years. Strahlenther Onkol. 2010;186:82-90.

21. Smith AC. Diagnosis and indications for surgical treatment. Hand Clin. 1991;7:635-642.

22. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012;129:469-477.

23. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361:968-979.

24. Chen NC, Srinivasan RC, Shauver MJ, et al. A systematic review of outcomes of fasciotomy, aponeurotomy, and collagenase treatments for Dupuytren’s contracture. Hand. 2011;6:250-255.

25. Peimer CA, Blazar P, Coleman S, et al. Dupuytren contracture recurrence following treatment with collagenase Clostridium histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-year data. J Hand Surg Am. 2015;40:1597-1605.

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27. Cheung K, Walley KC, Rozental TD. Management of complications of Dupuytren contracture. Hand Clini. 2015;31:345-354.

So how do the treatment options compare?

We found no randomized prospective trials comparing treatment options for DD, but there are a number of trials that shed light on a variety of the available options.

Treatment success. In general, partial fasciectomies have shown the greatest success in reducing contractures and maintaining the lowest recurrence rates. Correction of contracture to ≤5 degrees was seen in 94% of MCP joint contractures treated with partial fasciectomy, in 77% of MCP joints treated with collagenase, and in 55% of MCP joints treated with percutaneous needle fasciotomies.^22,23 PIP joint contracture correction was not as successful: Correction of contracture to ≤5 degrees was seen in 47% of those treated with partial fasciectomy, 40% treated with collagenase, and 26% treated with needle fasciotomy.^22,23

Recurrence rates. When recurrence was defined as loss of passive extension >30 degrees, the recurrence rate for MCP joint contractures with partial fasciectomy was 21%, compared with 85% for needle fasciotomy.²² In a similar review, recurrence rates for partial fasciectomy ranged from 12% to 39% compared with 50% to 58% for needle fasciotomy.²⁴ With collagenase injection, 5-year data have shown an overall recurrence rate of 32%, with a recurrence of 26% at the MCP joint and 46% at the PIP joint.²⁵ In this trial, recurrence was defined as more than 30% worsening of flexion.²⁵

Complications. Although fasciectomies have shown the best efficacy and lowest recurrence rates, complications such as infection, neurapraxia, and digital nerve injury are more likely with these procedures.^26,27

Early recognition and referral to a hand specialist for the treatment of DD may allow the use of less invasive techniques and improved functional results.

CASE › Absent a history of trauma and features typical of other hand/digit disorders, we diagnosed Dupuytren’s disease in this patient. Potential treatments included partial fasciectomy and collagenase injection. After discussing the risks and benefits of each of these procedures, the patient elected to undergo a partial fasciectomy. The surgery was uncomplicated and the abnormality was corrected to within 5 degrees of full extension. At the patient’s one-year follow-up visit, there was no evidence of recurrence.