What are the treatment options for a patient with Dupuytren's disease?

Treatment of Dupuytren's Disease

For primary Dupuytren's disease with metacarpophalangeal (MCP) joint contracture, collagenase clostridium histolyticum (CCH) injection is the preferred first-line treatment, offering excellent correction rates (88% achieve 0-5° extension) with minimal invasiveness, though patients must understand the higher recurrence risk compared to fasciectomy. 1, 2, 3

Treatment Selection Algorithm

For MCP Joint Contracture Only (Primary Disease)

• First-line: Collagenase injection - Current practice patterns show this is preferred by the majority of hand surgeons for isolated MCP involvement 2
• Achieves 88% correction to normal or near-normal extension (0-5°) within 1-14 days 3
• Requires two visits: injection visit and manipulation visit 24-72 hours later 1
• Alternative: Percutaneous needle aponeurotomy (PNA) - Achieves 84% good immediate results in early-stage disease with only 1.7% complication rate 4

For MCP + Proximal Interphalangeal (PIP) Joint Involvement

• Preferred: Limited fasciectomy - This is the treatment of choice when both joints are involved, as endorsed by 87.1% of surgeons who recognize it offers the longest disease-free interval 2
• Collagenase has lower success rates for PIP joints (only 44% achieve normal extension, 78% achieve within 15° of normal) 3

For Young, Active, Working Patients

• Consider limited fasciectomy over collagenase - 42.7% of surgeons prefer collagenase, but plastic and general surgeons favor fasciectomy in this population due to longer disease-free intervals 2
• This reflects the trade-off between minimizing recovery time versus minimizing recurrence risk in patients with longer life expectancy 1

For Recurrent Disease

• Dermofasciectomy is increasingly performed - Has the lowest recurrence rate but highest complication rate 5
• Critical warning: Secondary fasciectomy after previous dermofasciectomy carries up to 8% amputation rate 1

Specific Treatment Details

Collagenase Injection Technique

• Dose: 10,000 units injected directly into the cord causing contracture 3
• Doses below 10,000 units (300-9,600 U) showed no beneficial clinical effects 3
• pH considerations: Optimal enzyme activity occurs at pH 6-8; avoid acidic solutions and heavy metal antiseptics (mercury, silver) 6
• Avoid Dakin's solution; use normal saline for cleansing 6

Expected Outcomes by Joint

• MCP joints: 88% correction to 0-5° extension 3
• PIP joints: 44% correction to 0°, 78% correction to within 15° of normal 3
• Mean follow-up data: 20 months for MCP, 14 months for PIP 3

Percutaneous Needle Aponeurotomy (PNA)

• Best for early-stage disease with mild to moderate contractures 5, 4
• 84% good immediate results, but 12% recurrence rate 4
• Advantage: Immediate improvement with minimal invasiveness 1
• Disadvantages: Higher recurrence than fasciectomy, potential skin tears, rare tendon/nerve injury 1

Limited Fasciectomy

• Removes diseased tissue completely but requires more prolonged recovery 1
• Recognized by 87.1% of surgeons as offering longest disease-free interval 2
• Higher rate of significant complications compared to needle techniques 1

Common Complications and Side Effects

Collagenase-Specific

• Minor (common): Skin tears, localized swelling, bruising 1
• Rare but serious: Tendon rupture (must avoid injecting into tendons) 1
• Slight transient erythema in surrounding tissue if not confined to wound 6

Fasciectomy-Specific

• Higher rate of significant complications than minimally invasive options 1
• Prolonged recovery period 1

PNA-Specific

• Problematic skin tears 1
• Rare tendon or nerve complications 1

Critical Pitfalls to Avoid

1. Do not use collagenase doses below 10,000 units - Lower doses (300-9,600 U) are ineffective 3

2. Avoid contamination with incompatible substances - Heavy metal antiseptics and acidic solutions inactivate collagenase 6

3. Do not perform secondary fasciectomy after dermofasciectomy without serious consideration - Amputation risk reaches 8% 1

4. Confine collagenase application strictly to the cord - Application to surrounding tissue causes erythema and increases complication risk 6

5. Monitor debilitated patients closely - Theoretical risk of bacteremia with enzymatic debridement 6

Observation vs. Intervention

While the evidence does not specify exact thresholds, intervention is typically indicated when contracture causes functional impairment 1, 5. The choice between observation and treatment depends on contracture severity, joint involvement, patient age/activity level, and patient preference regarding recovery time versus recurrence risk 2.