Treatment of Dupuytren's contracture

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Dupuytren's contracture is a hand deformity that develops over the years. Pathological changes affect the palmar aponeurosis - a sheet of connective tissue under the skin of the palm. Nodules of tissue that form under the skin unite into a dense fibrous band and can pull one or more fingers into a permanently flexed position.

NB! Contracture of the fingers (a forced position with limited movement) is not always caused by palmar fibromatosis. Limitation of movement may be caused by trauma or neurological disorders.

The affected fingers do not fully extend, which makes everyday hand function difficult: difficulty putting your hand in a pocket, difficulty or impossible to put on gloves, difficulty shaking hands.

Dupuytren's contracture usually affects the ring or little finger and is more common in older men. A doctor has some tools in his arsenal that can make life easier for a person with Dupuytren's contracture.

Symptoms

The disease progresses slowly, usually over several years. Dupuytren's contracture begins with the appearance of lumps on the palm. Gradually, the skin wrinkles and characteristic indentations appear. You can feel a firm mass under the skin, which may be tender to the touch but is rarely painful.

In later stages of Dupuytren's contracture, strands of fibrous tissue from the palm extend to the fingers. As it progresses, these cords may curl the fingers toward the palm.

Most often this happens with the little finger or ring finger, but it also happens with the middle finger. The thumb and index finger are rarely involved in the pathological process.

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There are frequent cases of bilateral lesions. One hand is usually more involved than the other.

Types and symptoms

There are several types of Dupuytren's syndrome:

• finger,
• palmar,
• mixed
• common

This disease is not life-threatening. However, a person loses the ability to fine motor skills, feels stiffness in movements, fatigue in the hand, funnel-shaped deformation, and the presence of a scar in the tissues.

The nature of the development of the syndrome varies:

• primary - observed in people over 50 years of age, develops over 10 years,
• secondary - manifests itself completely within 3-5 years in patients under 45 years of age,
• mixed - more common in people under 35 years of age, progresses quickly (in just 1.5 years),
• malignant - occurs in children with a hereditary predisposition, develops rapidly, and affects the palmar and plantar aponeurosis, as well as the aponeurosis of the male genitalia.

Risk factors

Although we do not know the exact cause, there are some factors associated with this pathology:

• Age. Dupuytren's contracture most often occurs after 50 years of age.
• Floor. Men are significantly more susceptible than women. Severe degrees of the disease are more common in men.
• Heredity and genetics. The disease is often inherited. Dupuytren's contracture is typical for residents of northern Europe.
• Tobacco and alcohol. Smoking increases the risk of developing Dupuytren's contracture, possibly due to capillary damage and chronic tissue ischemia. Alcohol abuse also worsens the prognosis.
• Diabetes. There are reports of an increase in the incidence of Dupuytren's contracture among diabetics.

Palmar fibromatosis

Dupuytren's contracture
is a fairly common hand disease. Most often the ring finger and (or) little finger are involved in the process. Often Dupuytren's contracture develops simultaneously on both hands. The exact cause of the disease is unknown. It is most common in middle-aged men. There is a clear hereditary predisposition to this disease. The incidence of this disease in men is several times higher than in women. Residents of Scandinavia, Ireland and people from Eastern Europe are most susceptible to this disease. The disease may have an acute onset, but in most cases, severe symptoms appear only several years after the onset of the disease.

Complications

Dupuytren's contracture impairs hand function. Since the thumb and index fingers are rarely used, many people cope with everyday tasks for quite a long time - with three fingers it is quite possible to write and pick up small objects. As it progresses, it becomes impossible to fully open the palm and grasp large objects (grasp) or fit the hand into narrow spaces (pockets). In later stages, dirt can accumulate in permanent folds of the skin and cause ulcers that will not heal.

Preparation for inspection

Of course, you can show your hand to your local therapist or surgeon at the clinic. He will refer you to a hand surgery specialist.

Before the inspection, formulate answers to the following questions:

• Do your relatives have similar problems?
• What treatment have you already tried? How did this help?
• What medications do you use regularly?

The doctor will also ask you:

• How long ago did you notice the first symptoms?
• Does it get worse over time?
• Is there pain in your hand?

How much does contracture interfere with everyday life?

Treatment

Because the disease progresses slowly, is not painful, and is not always very bothersome, treatment may not be required. In the initial stages, observation may be sufficient. The palm-on-table test can be performed at home at some intervals.

Treatment consists of destroying or removing the cords that tighten the fingers. This can be done in several ways. The choice depends on the degree of contracture, comorbidities, and patient and surgeon preference. No matter how radical and categorical this may sound, at the moment Dupuytren’s contracture = surgery.

Needle technique

The fibrous cord can be crossed with an injection needle through punctures in the skin and the finger can be straightened. The contracture usually returns, then the procedure can be repeated.

The main advantage of needle (or needle) aponeurotomy is that there is no incision, and the operation can be performed on both arms at the same time.

Postoperative management is simple and the person quickly returns to normal activities. The main disadvantage is an earlier relapse and the possibility of damage to the nerve or tendon (which is extremely rare in reality).

Needle aponeurotomy can also be used for the staged treatment of severe Dupuytren's contracture. At the first stage, the fibrous cord is unbent with the help of punctures; as a rule, it is not possible to bring it into a straight position, but it is possible to transfer the 4th stage to the second. A person immediately becomes more comfortable using his hand. And after 5-6 months it is already possible to carry out a full-fledged open aponeurotomy and “adjust the finger.” This method allows you to speed up rehabilitation after surgery and reduce the risk of complications, because during the time between stages the skin has time to stretch, and the joints “remember” their normal range of motion.

Surgery for Dupuytren's contracture

The purpose of the operation for Dupuytren's contracture is to remove or dissect the scarred aponeurosis of the palm, which allows the fingers to be straightened. By removing or cutting the altered areas of the aponeurosis, the flexion contracture of the fingers will be eliminated.

The decision to perform a particular method of surgery should be made together with the orthopedic surgeon. You should know as much as possible about the operation, consequences, and complications. If you have a chronic condition or have any questions, you should talk to your surgeon about it.

If you decide to have surgery, you must undergo blood tests: clinical blood test, general urine test, biochemical blood test, blood sugar, coagulogram, test for HIV, hepatitis B, C.

Surgical treatment of Dupuytren's Contracture is usually performed on an outpatient basis under general anesthesia, i.e. Only the hand is anesthetized - the patient returns home a few hours after the operation.

Aponeurotomy

The very first of the described surgical techniques for the treatment of this disease.

Needle aponeurotomy (Percutaneous fasciotomy)

Needle aponeurotomy is, in principle, possible at any stage of contracture, but in severe cases a staged approach will be required, i.e. gradual extension of the finger. With severe contracture, up to 3 manipulations may be needed. Under general anesthesia, the surgeon inserts a needle under the skin. And gradually dissects the scar cords of the aponeurosis at different levels of the palm and fingers. This allows you to straighten your finger(s) to normal. This method is indicated for patients who categorically refuse classical surgery for personal reasons (postoperative scars, fear of surgery, inability to leave work) or patients with any chronic diseases that are a contraindication for open surgery. For example, decompensated diabetes mellitus, hypertension (with systolic pressure more than 200 mmHg)

The advantages of needle aponeurotomy are:

• Low invasiveness of the operation;
• A quick rehabilitation period and the ability to develop fingers immediately after surgery;
• Low risk (about 1%) of complications.

The disadvantage is the high recurrence rate because the aponeurotic tissue is not removed and may continue to scar under the skin, causing the flexion contracture to return, but often to a lesser extent.

Open aponeurotomy

Open aponeurotomy is sometimes used to treat more severe cases of Dupuytren's contracture. The technique is more effective in the long term than needle aponeurotomy, but is a more extensive operation and therefore carries additional risks (see below).

Like needle aponeurotomy, open surgery is performed on an outpatient basis under local or regional anesthesia.

Advantages of the technique: low invasiveness of the operation, short operation time.

The disadvantage of the technique is that the affected aponeurosis is not removed and can continue its pathological scarring further, leading to relapse of the disease in 90% of cases.

Aponeurectomy (aponeurectomy)

The second group and the most popular technique is excision of the aponeurosis (partial, total).

Partial aponeurectomy

The most commonly used type of operation for Dupuytren's contracture, when only scarred areas of the palmar aponeurosis are removed.

Total (complete) removal of the palmar aponeurosis

With this technique, changed and unchanged areas of the aponeurosis are completely excised. The disadvantage of this type of operation is that if unchanged areas are affected, there is no guarantee that they are completely removed. This, in turn, can provoke a new development of the disease. The volume and time of the operation also increases.

Complications

For needle aponeurotomy, the complication rate is low, within 1%.

For open aponeurotomy, the complication rate is higher, approximately 5%.

What could go wrong?

Complications can occur with any surgical procedure. Some of the most common complications after surgery for Dupuytren's contracture are:

Inflammation of a postoperative wound.

Hematoma;

Hypertrophic or tightening scars;

Damage to a nerve or blood vessel.

Medication injections

Injecting drugs directly into fibrous tissue can soften or destroy it.

At the time of writing (May 2021), the situation in Russia is as follows:

Pfizer's drug Xiapex is not registered. It is the only collagenase in the world certified for the treatment of Dupuytren's contracture.

Collalysine is not certified for the treatment of Dupuytren's contracture, and I have never learned how to achieve the right concentration.

Fermenkol is at the stage of certification of the injection form.

Kenalog (not an enzyme, but a glucocorticoid) is certified for local injection and is an excellent softener for fibromatous nodes.

Operation

The fibrous cord can not only be cut under the skin, but also completely removed. The main advantage of open surgery is the most complete and long-lasting effect compared to closed methods.

The main disadvantage of a full-fledged operation is the longer recovery. The sutures are removed after 2 weeks and the same or even more may be needed to restore function.

In any case, no matter what treatment method we choose, I have no reason to admit the patient to the hospital. Any treatment for Dupuytren's contracture can be performed on an outpatient basis using local anesthesia (unless, of course, you are allergic to local anesthetics).

Conservative treatment of Dupuytren's contracture

Conservative therapy can slow down the progression of Dupuytren's disease and increase the degree of finger mobility.
However, in most patients, Dupuytren's contracture has a progressive course and sooner or later the question arises about the need for surgery. For the initial manifestations of Dupuytren's contracture, it is recommended:

• periodic observation by an orthopedist;
• conducting physiotherapy;
• physical therapy (physical therapy) aimed at stretching the palmar aponeurosis;
• Using a splint on the hand to fix the fingers in the extension position during sleep.

Collagenase injection

Collagenase injection is a fairly new method of conservative treatment of Dupuytren's contracture, which was recently approved for use in European countries. The essence of the technique is as follows:

The drug is injected into the nodules or cords of aponeurosis under the skin that form as the disease progresses. The medicine contains enzymes that destroy the structure of collagen fibers of the scar aponeurosis.

After injection of the drug, it is prohibited to perform active actions with a brush. After 24 hours, the patient comes to the doctor to perform the second stage of treatment, namely, to straighten the fingers. Do not straighten your fingers on your own for the first 24 hours. The hand should be in a relaxed state so that the injected drug does not spread over the surrounding tissues, this can cause inflammation, swelling, and pain.

If the first injection is not effective, a repeat injection is prescribed, but not earlier than a month later.

According to various studies, 70% of patients were able to fully straighten their fingers after collagenase injection. The relapse rate is from 50% to 80%, because... the affected aponeurosis is not removed.

The most common side effects of the procedure are swelling, hemorrhage, and pain around the injection site. They pass quite quickly, in 10-14 days.

Treatment after surgery

Immediately after suturing the skin, a large sterile bandage is applied, and the hand is placed on a scarf. During the first day, a lot of blood is usually released, so I always wrap a thick “mitten” around my hand. For the first 2-3 days, the hand should be held higher, trying not to lower it below the level of the heart. As soon as the anesthesia wears off (which is 3-4 hours after surgery), you should take painkillers.

Before the stitches are removed, we will meet several times, gradually your “mitten” will become thinner, and your arm will hurt less and less. After 2 weeks, the stitches are removed. It does not hurt! Sometimes it happens that the bandage remains on the arm even after the stitches are removed. With severe contracture, marginal necrosis of the flaps and longer healing of the transverse approach are possible.

After the wound has healed, you can wash your hand and start using it. Under the scars, the skin is initially hard and inactive. It needs to be softened with massage, hand cream, movements and physiotherapeutic procedures.

NB! Classes with a hand therapist improve the results of treatment of Dupuytren's contracture.

Plaster and other means of immobilization are used very rarely, only in special cases.

Full restoration of hand mobility after open aponeurotomy should be expected no earlier than 2 months.

Sequence of the operation:

• Drawing the cutting line (Fig. 4)
• Skin incision
• Carefully prepare the skin as thick as possible so as not to damage its blood supply and avoid necrosis (death of areas of the skin).
• Separation of painfully altered palmar aponeurosis at the height of the wrist.
• Removal of the palmar aponeurosis in the direction from the wrist to the fingers with permanent release of the neurovascular bundle leading to the fingers.
• In the area of ​​the fingers, preparation of the neurovascular bundle is more difficult, although the nerves during the primary operation are not fused with the cords, but they can be spirally entwined with them (the so-called Iselin nerve).
• Contractures, in most cases of the middle joints, disappear, as a rule, after excision of the scar cords themselves or under pressure. Sometimes surgical straightening of the joint is necessary, depending on the severity of the contracture.
• After removal of contracture tissue, the integrity of the neurovascular bundle is rechecked.
• The success of the operation can be checked visually and by touch.
• Laying drainage using the Redon method to drain postoperative bleeding to avoid hematomas in the palm area.
• Removing the bleeding cuff, stopping the bleeding, first by applying pressure to the wound, then by electrocoagulation (cauterization) of still bleeding vessels.
• Suture
• Pressure bandage with steel wool
• Immobilization with a plaster splint