Dupuytren’s disease consists of a retraction of the palmar fascia that prevents its normal sliding on the skin of the palm of the hand. Progressively, both structures are retracted and, subsequently, the fingers of the hand.
Cause of Dupuytren’s disease
The cause of Dupuytren’s is unknown, although it may be related to diabetes, epilepsy (phenytoin consumption), or alcoholism.
It is believed to be a hereditary disease with some family component, although sometimes there is no risk factor. It is exceptional in the black race. It affects men more frequently than women, being more common after 40 years of age.
At the origin of Dupuytren’s disease, there is a transformation of fibroblasts that form type I collagen and do not have contractile capacity, to myofibroblasts that form type III collagen and do have contractile capacity.
Dupuytren’s disease begins with the formation of nodules first, which progresses to the formation of cords later. The cords may shrink the metacarpophalangeal joint first, and the interphalangeal joint second.
The most affected fingers are the 4th and 5th, affecting a single finger in a third of cases, two fingers in another third and more than two fingers in another third.
Dupuytren’s surgery is indicated when you have a retraction of the metacarpophalangeal joint that prevents you from placing your hand flat on the table, or when you have a retraction of the proximal interphalangeal joint greater than 15º.
The degree of retraction of the fingers in Dupuytren’s disease, mainly the flexion of the proximal interphalangeal joint, is the fundamental prognostic factor for surgical results. If the proximal interphalangeal joint is flexed, surgery should not be delayed.
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Surgical treatment of Dupuytren disease
Selective Fasciectomy
It has been and continues to be the most performed surgery for Dupuytren’s disease.
It may consist of selective fasciectomy (removal of the diseased fascia) or percutaneous fasciotomy (cutting of the fascia to achieve extension).
Selective open fasciectomy consists of removing the diseased Dupuytren’s fascia. It is done with ischemia (a cuff placed on the arm to prevent bleeding), it requires opening the skin, giving stitches, dissecting the nerves and vessels and removing the diseased fibrous tissue.
It may be necessary if the toe is severely retracted, Z-plasties and flaps to increase the length of the skin. If Dupuytren’s disease recurs after surgery, skin grafting may be necessary.
In addition, if there is a flexural rigidity of the proximal interphalangeal joint that cannot be reduced, a release of the palmar plate of the joint must be performed. The most important complication is neurovascular injury and recurrence (50% at 15 years).
Enymatic fasciotomy with colagenase with Dupuytren disease
It has become very popular in recent years. It was incorporated in Spain in 2011 and consists of injecting a toxin (collagenase) into the cord of Dupuytren’s disease. When injected and during the following 16 hours, it causes a progressive destruction of the bridle, allowing 24-48 hours to be able to stretch the finger and break the tissue.
This is what is called enzymatic fasciotomy in Dupuytren’s disease. Between 2012 and the present, we have an experience with 235 patients treated with collagenase, obtaining very good clinical results.
The advantages are:
- It does not require preoperative care, it is done in the office (not in the operating room), and it does not require stitches or any surgical aggressiveness.
- It is a good alternative to avoid skin damage, especially in young patients, where recurrences can be frequent.
- It is one of the techniques that I have used the most, and where patients are most satisfied.
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Ultrasound guided aponeurotomy in Dupuytren’s disease
It consists of cutting the Dupuytren’s cords, under direct vision with the ultrasound probe, without incisions and using the bevel of a needle of different thicknesses. With the ultrasound machine we avoid damaging the nerves, the tendon and the vessels by having these structures under control at all times.
It is performed with local anesthesia and without ischemia (without leaving the hand without irrigation).
Ultrasound also allows the release of the volar plate from the proximal interphalangeal joint in a safe and less traumatic way than open arthrolysis.
In the most serious cases, to avoid skin complications, it can be done in 2 or 3 stages, all of them on an outpatient basis, complementing the surgical treatment with physiotherapy.
Now we have more than 150 cases treated with this technique with great results. We have a paper in Journal of Hand Surgery with the first 70 cases, showing the technique and our results.
Now is our preference technique, for treatment of Dupuytren´s disease and proximal PIP arthrolysis.
Case 1 Ultrasound guided surgery in Dupuytren disease
Case 2 Ultrasound guided aponeurotomy Dupuytren 4th and 5th finger
Case 3 Ultrasound guided aponeurotomy fourth finger with Dupuytren
Looking at these examples of patients treated with the ultrasound-guided technique for Dupuytren’s disease, we see the following advantages:
- No need for preoperative.
- The hand is without an ischemia cuff.
- The patient can move the fingers and check the result immediately.
- Points are not required.
- The patient can lead a normal life after 48 hours, even being able to drive.
- We can treat Dupuytren at different stages of the disease
- Aponeurotomy and arthrolisis can be performed in severe cases.
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Physiotherapy
Collaboration with occupational therapists for postoperative thermoplastic extension braces and exercises is important. If there is no proximal interphalangeal retraction, they do not require physiotherapy treatment.
Frequent questions to answer about Dupuytren’s disease
Is it a hereditary disease?
There are patients in whom there is a hereditary component, although sometimes there is no family history or risk factor.
How long does it take to develop?
It is very variable. There are patients who take less than 2 and a half years and others, however, more than 10 years. The greater the number of risk factors, the faster the progression of the disease, but this is not always the case.
If I have surgery, will the disease disappear forever?
Dupuytren’s disease, like other chronic diseases such as high blood pressure or diabetes, is a lifelong disease. Therefore, it can reappear in other locations and even in the area of the surgery.
Can I have both hands operated on with Dupuytren at the same time?
With a conventional open surgery NO. With ultrasound-guided surgery, both hands can be operated at the same time.
What are the advantages of ultrasound-guided surgery at the Dupuytren?
Little aggressive. No incisions, intact skin is preserved, faster recovery. Control at all times of important structures by always seeing with the ultrasound machine. No preoperative study required.
When can I drive after an ultrasound-guided surgery?
At 24-48 hours if the dupuytren is not very important.
«In the treatment of Dupuytren the most important thing is the indication of treatment»
“Being a disease for life, you have to have a good treatment strategy”
“Ultrasound-guided fasciotomy is an excellent safe and reliable treatment method”
“INDICATION AND STRATEGY OF DUPUYTREN, ARE THE KEYS TO SUCCESS”
¿Quieres conocer el testimonio de un paciente intervenido de Dupuytren con colagenasa sin cirugía?
