What are the treatment options for Dupuytren's contracture?

Treatment Options for Dupuytren's Contracture

The most effective treatment for Dupuytren's contracture depends on disease severity, with surgical fasciectomy providing the most durable long-term results for advanced contractures, while less invasive options like collagenase injections or needle fasciotomy are appropriate for milder cases.

Understanding Dupuytren's Contracture

Dupuytren's contracture is a progressive fibroproliferative disorder affecting the hands, causing permanent flexion contracture of the digits due to thickening of tissue under the palmar skin. Risk factors include:

• Advanced age
• Male sex
• Northern European ancestry
• Positive family history
• Diabetes mellitus

Treatment Options Based on Disease Severity

Non-Surgical Management

• Physical Therapy and Exercises:

  • Daily stretching exercises to maintain joint mobility 1
  • Warm-up with low-intensity exercises before stretching 1
  • Limited evidence for effectiveness as standalone treatment

• Orthoses/Splinting:

  • Evidence suggests postoperative splinting may not improve outcomes and might reduce active flexion 2
  • May be considered for symptom relief in early disease 1

Minimally Invasive Procedures

1. Needle Fasciotomy/Aponeurotomy:

• Best for:
  • Elderly patients with milder contractures
  • Patients seeking less invasive options
  • Metacarpophalangeal (MCP) joint contractures
• Advantages:
  • Shorter recovery time
  • Lower complication rate
  • Office-based procedure
• Disadvantages:
  • Higher recurrence rate (85% at 5 years vs 21% with fasciectomy) 2
  • Less effective for severe contractures and PIP joint involvement

1. Collagenase Clostridium Histolyticum Injections:

• Enzymatic disruption of collagen cords
• Success rates:
  • 80% for MCP joints
  • 39% for PIP joints 3
• High patient satisfaction (78/100 on VAS) 3
• Advantages:
  • Non-surgical option
  • Minimal recovery time
  • Good safety profile

Surgical Options

1. Limited Fasciectomy:

• Gold standard surgical treatment
• Involves removal of diseased fascia
• Best for:
  • More severe contractures
  • Younger patients
  • Recurrent disease
• Advantages:
  • More durable correction than minimally invasive options
  • Better correction of severe contractures
• Disadvantages:
  • Longer recovery period
  • Higher complication risk
  • More extensive scarring

1. Dermofasciectomy with Skin Grafting:

• Removal of diseased fascia and overlying skin
• Replacement with full-thickness skin graft
• Best for:
  • Recurrent disease
  • Aggressive disease with Dupuytren's diathesis
  • Young patients with strong family history 4

Treatment Algorithm

1. Mild Disease (contracture <30°, primarily MCP involvement):

   • Observation if not functionally limiting
   • Consider needle fasciotomy or collagenase injection if treatment desired

2. Moderate Disease (contracture 30-60°):

   • Collagenase injection for MCP joint contractures
   • Limited fasciectomy for PIP joint contractures or if multiple digits involved

3. Severe Disease (contracture >60°, PIP involvement):

   • Limited fasciectomy as primary treatment
   • Consider dermofasciectomy for recurrent cases or aggressive disease

Postoperative Management

• Early active-flexion range-of-motion exercises to restore grip strength 4
• Hand therapy to maximize functional outcomes
• Avoid routine postoperative splinting as evidence suggests it may not improve outcomes and could impair active flexion 2

Recurrence Considerations

• Higher recurrence rates with:
  • Needle fasciotomy (85% at 5 years) 2
  • Young age at onset
  • Strong family history
  • Multiple digit involvement
  • PIP joint involvement

Complications to Monitor

• Skin tears or wounds
• Digital nerve injury
• Vascular compromise
• Complex regional pain syndrome
• Infection
• Hematoma

Dupuytren's contracture is a chronic condition with no definitive cure. Treatment should focus on functional improvement rather than complete eradication of disease, with the understanding that recurrence is common regardless of treatment modality 5.