Treatment of Dupuytren disease

Dupuytren disease is a genetic condition of abnormal collagen deposition in the palmar fascia of the palm and fingers. Within the workers’ compensation setting, claims are usually accepted for an aggravation of the pre-existing disease, frequently due to a significant one-event trauma or after exposure to significant repetitive trauma.

For centuries, surgical excision of the diseased palmar fascia was the gold standard of treatment for Dupuytren disease. During surgery the palm, fingers, or both are opened, thickened cords and nodules are excised, joint contractures are corrected as much as possible, and often multiple z-plasties are done to correct skin deficiencies. While recurrences are unlikely, the disease can later present in neighboring areas. The surgery leaves significant scar tissue, requires lengthy recovery with extensive hand therapy, and has a complication rate between 3.6% and 39%.[1] As a result more minimally invasive techniques have been developed in the past 20 years.

Needle aponeurotomy or percutaneous needle fasciotomy
In the 1990s releasing cord contractures with a less-invasive needle technique showed promising results. Needle aponeurotomy is a minor procedure performed either in the office or outpatient clinic. The diseased cord is marked every 6 to 8 mm and these sites are then infiltrated with micro-aliquots of 1% lidocaine (usually 0.1 cc), which anesthetizes the skin only, not the digital nerves. A 23- to 25-gauge needle is then inserted and swept side to side to release the cord at each planned fasciotomy site. Patients can watch the digit straighten with each successive release and provide feedback for neuromatous pain (or electric shocks) so that nerve injury is prevented. Immediate full range of motion is encouraged, and recovery time is 24 to 48 hours, limited only by pain and bruising. Skin tears can occur and tendon ruptures through inadvertent transection of the tendon have been reported. A night extension splint is worn for 4 to 6 months to reduce recurrence. Some advocate steroid injections at release sites to reduce recurrences. Recurrence rates are the main limitation and are 65% at 5 years;[2] however, the procedure can be repeated and does not preclude future surgery.

Collagenase clostridium histolyticum injection
This newest treatment for Dupuytren disease is the injection of the bacterium clostridium histolyticum, which produces an enzyme that breaks down collagen. The diseased cords are injected in up to three places and the enzyme is allowed to sit for 24 to 72 hours. Patients return for the application of passive stretch, and the cords should rupture at each injection site level. Since the cord is ruptured at numerous levels, results are similar to those of needle aponeurotomy, with little difference in outcomes, but earlier recurrence after collagenase. Side effects can include pain and inflammation from a reaction to the enzyme, skin tears during stretching, regional lymphadenopathy, axillary pain, rare allergic reactions, tendon rupture, and cold intolerance.[3]

Limited palmar fasciectomy
While narrow cord type Dupuytren disease can be treated well with both needle aponeurotomy and collagenase, thick nodules sometimes require a localized excision, particularly if the mass effect of the nodule is bothersome to the patient during gripping activities. Also, contractures that do not respond well to less-invasive treatments or recur within 1 year after treatments are candidates for surgery. Patients who had a favorable response to prior surgery may also elect to proceed directly to surgery.

Further information
For further information or assistance with a patient who has a WorkSafeBC claim for Dupuytren disease, please contact a medical advisor in your nearest WorkSafeBC office. 
—Rodney French, MD, MEd, FRCSC
WorkSafeBC Visiting Specialists Clinic Consultant

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This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Denkler K. Surgical complications associated with fasciectomy for Dupuytren’s disease: A 20-year review of the English literature. ePlasty 2010;10:116-133.
2.    van Rijssen AL, Werker PM. Percutaneous needle fasciotomy in Dupuytren’s disease. J Hand Surg Br 2006;31:498-501.
3.    King IC, Belcher HJ. Cold intolerance following collagenase Clostridium histolyticum treatment for Dupuytren contracture. J Hand Surg Am 2014;39:808-809.