Treatment of Dupuytren's Disease

Abstract

Update This article was updated on June 12, 2020, because of a previous error. An erratum (JBJS JOPA. 2020;8[2]: e0024ER) has been published for this article. Dupuytren's disease is a benign fibromatosis that affects the palmar and digital fascia. The pathology associated with the development of Dupuytren's disease is the cause of some debate. Patients usually present with firm dense nodules or cords that cause flexion contractures of the metacarpal phalangeal (MCP) joints or proximal interphalangeal (PIP) joints. The severity of contracture, amount of functional impairment, and patient desired treatment will have an effect on the overall recovery following treatment. Historically, the standard of care for Dupuytren's disease was open surgical fasciectomy, percutaneous/open fasciotomy, and needle fasciotomy. Indications for surgical intervention include patients with functional impairment and metacarpophalangeal joint contractures of 30° or more. Collagenase Clostridium histolyticum (CCH), (enzymatic fasciotomy), which lyses collagen and leads to disruption of contracted cords, is an office-based, minimally invasive, nonsurgical option for the treatment of advanced Dupuytren's disease. Many of the studies looking at treatment with collagenase/manual manipulation have reported favorable 5-year outcomes. These studies have shown near-normal return of range of motion at the MCP and, to a lesser extent, PIP joints. The side effect/adverse effect profile has been promising. Injection sight pain and skin tears are the more commonly reported events associated with CCH therapy. Surgical fasciotomy has reported the most severe adverse effects consisting of sensory, motor, and vascular injuries. Physicians have used extension orthoses postoperatively to maintain finger extension following fasciotomy vs. fasciectomy. Some research studies have questioned the value of extension splinting indicating that the tension placed on the contracted tissue can lead to local tissue hypoxia. This has been reported to trigger a flare reaction and thus lead to more increased scar tissue formation. The treatment of Dupuytren's disease requires a comprehensive assessment of the patients' physical limitations; most consider cost-effective therapies that have limited adverse effects and provide long-term improvement in their daily functional activities.