Dupuytren’s contracture - treatment choices compared

There are many treatment options for Dupuytren’s contracture, but the right treatment depends on the severity of the disease and whether or not you’re experiencing recurrence. We asked leading plastic surgeon Mr Oliver Harley to explain when treatment for Dupuytren’s contracture is needed and how the different treatment options compare.

What is Dupuytren’s contracture?

Dupuytren's contracture, or Dupuytren’s disease, is a condition which typically runs in families and may have originated amongst Viking populations. It occurs spontaneously, but it can occasionally follow a small injury or operation.

In Dupuytren’s contracture, the layer immediately under the skin of the palm and fingers thickens and tightens. It does not affect the tendons – although this is a common misconception. Gristly lumps or cords form in the hand and fingers and these can be sore or itchy to begin with. It usually affects the little or ring finger but any combination of fingers and thumbs may be involved simultaneously or at different times. All or any of the three joints in each finger can become contracted.

The contracted finger(s) make some functions difficult – such as putting hands into pockets or gloves, manipulating certain objects, or washing your face. The contracture never settles on its own and usually continues to worsen - sometimes quickly and sometimes slowly.

When is treatment needed?

Dupuytren’s disease is not dangerous but it is typically progressive (meaning it gets worse over time). A similar process can also happen on the soles of the feet ( Lederhosen disease) and also in the penis (Peyronie’s disease). Once contracture occurs to a significant degree (approximately 30 degrees or more), treatment is recommended. This involves physically removing or disrupting the tight Dupuytren’s tissue to allow the finger to become straighter.

The timing of treatment is important. The longer it is left untreated and the more severe the contracture, the more difficult it is to get a good result, because the bones and ligaments of the finger joints start to be damaged. This is especially true where the mid joint of the finger (the ‘PIP joint’) is contracted.

It is not possible to completely eradicate Dupuytren’s. Treatments aim to improve hand function, allowing the fingers to move better. Unfortunately, recurrence occurs quite frequently but it is preferable to keep the disease under control, and further treatment is available for recurrent cases.

Your treatment options

Various treatments for Dupuytren’s contracture are available, listed in order of increasing ‘invasiveness’:

Radiotherapy

Courses of radiation have been trialled. It may be that early-stage disease (little or no contracture) can be slowed or reversed by this treatment. For more advanced disease, this treatment is unlikely to improve the position of the finger, but it may slow progression of disease. Typically, one or two weeks of daily radiotherapy would be required. Radiotherapy is not available on the NHS and its role in the management of Dupuytren’s disease is the subject of ongoing evaluation.

Suitable for: early-stage disease (little or no contracture)
Not suitable for: advanced disease

Collagenase injection(Xiapex®)

Collagenase is an enzyme which is injected directly into the tight Dupuytren’s cords. Segments of the cord are digested by the enzyme, allowing the finger to be straightened at a second visit a few days after the injection. This treatment is carried out using local anaesthetic, and can only treat one or two fingers at a time. The key benefits are that the treatment involves minimal downtime, and you don’t typically need hand therapy.

Suitable for: well-defined cords in the palm and in the finger
Not suitable for: very severe contracture
Recurrence rate: 40-50%

Fasciotomy

In a fasciotomy the cords are severed in a few places through small cuts in the palm, either with blade or needle (“needle aponeurotomy” or “ needle fasciotomy”). Like collagenase injections, this treatment involves only local anaesthetic, but the advantage is that multiple fingers can be treated. Only one visit is required, and hand therapy is not needed.

Suitable for: well-defined cords in the palm only
Not suitable for: very severe contracture
Recurrence rate: 40-50%

Fasciectomy

This is the ‘gold-standard’ of treatment where nearly all the tightened, diseased tissue is removed at surgery and secondary contractures of joint ligaments can be addressed. Surgery usually involves just local anaesthetic but sometimes general anaesthetic may be required. You will be left with a zig-zag scar from palm along finger, and several sessions of hand therapy are essential after surgery.

Suitable for: mild as well as severe contractures
Recurrence rate: approx 25%

Dermofasciectomy

In some situations, larger areas of skin must be removed with the diseased dupuytrens tissue and a patch of grafted skin (taken from the forearm or upper arm) is used to replace this and to create a ‘fire-break’ against further tightening.

Usually this treatment is reserved for recurrent Dupuytren’s contracture, but it may be used as a first treatment for very severe disease. Sometimes it can be carried out using just local anaesthetic, but more often general anaesthetic is necessary.

In terms of recovery, you will wear a bandage for a few weeks after surgery, and you may need dressings for longer if the skin graft fails. You will also require hand therapy appointments. For the first couple of weeks you will need to avoid activities such as driving.

Suitable for: recurrent or severe contractures

Amputation

Occasionally, amputation may be preferable in the severely contracted finger which may have already had previous operations for Dupuytren’s contracture. Very rarely, it may be necessary to amputate a finger where the blood supply has failed during or after fasciectomy or dermofasciectomy.

If you would like to discuss Dupuytren’s contracture treatment options further with Mr Harley, click here to book a consultation.