Dupuytren’s contracture

What is Dupuytren’s disease?

Dupuytren’s disease or Dupuytren’s contracture is a thickening of the fascial tissue of the palm. This is the tough connective tissue that lies between the skin of the palm and the deeper nerves, blood vessels and tendons – think of it as the gristle of your palm. In people with Dupuytren’s disease, this tissue becomes overgrown, leading to lumps in the palm of the hand (called Dupuytren’s nodules), as well as indentations (known as pitting), and eventually thick bands (Dupuytren’s cords). These lumps and bands of tissue can be mildly uncomfortable at first. But over time, they can gradually cause the affected fingers to be pulled down into a fist to the point that the fingers can no longer be straightened. This can lead to great difficulty in using the hand. It is important to know that Dupuytren’s is not a tumor or a cancer.

What causes Dupuytren’s disease?

Dupuytren’s is a genetic disease, and most commonly affects people with Northern European ancestry. It’s thought that the Vikings may have brought the disease to the parts of Europe that they colonized in the 9th and 10th centuries. However, we don’t know exactly which genes are responsible for Dupuytren’s, and there is no genetic test to diagnose it. We do know that there are certain factors that increase the risk of developing Dupuytren’s disease:

  • The disease runs in families. You are at higher risk if you have immediate family members who have Dupuytren’s disease.
  • Men get Dupuytren’s disease more often than women
  • It becomes more common with increasing age. Most patients with Dupuytren’s are in their 40s or older
  • It is more common in patients with diabetes, epilepsy, and in smokers

There is no firm evidence yet that hard manual labor or exposure to vibration can cause Dupuytren’s, but some studies have suggested that there may be a connection. In the same way, there is no firm evidence that hand injuries can cause Dupuytren’s. But there is a lot of anecdotal evidence that trauma to the hand can “turn on” the Dupuytren’s genes. So trauma such as an injury, or a surgery, can lead to formation of nodules or cords.

Dr. Purushottam Nagarkar, University of Texas Southwestern Medical Center, Dallas, Plano and Frisco
Dr. Nagarkar on Dupuytren’s:

Dupuytren’s contracture is probably more common than carpal tunnel syndrome, but few patients have heard of it. Luckily, this is because most cases of Dupuytren’s disease don’t require any treatment. My approach to Dupuytren’s is to speak softly and carry a big stick. As long as the disease is not causing your fingers to bend down, it is best to leave it alone – because it may never bother you. But the moment it starts to cause trouble, I like to treat it thoroughly. This is because it is a much easier recovery when the disease is treated early rather than late.

What are the treatment options?

The goal of treatment is to make sure the fingers can straighten all the way and you can use your hand normally. There are a few different ways of achieving this, and each method has its benefits and downsides.

It is important to realize that there is no cure for Dupuytren’s disease. The condition is genetic – so each cell in the palm of your hand has the potential to create new nodules or cords. All the available treatments are designed to help your symptoms and allow the hand to work well again. This means that regardless of the treatment you have, there is a chance that the disease will return.

Remove the cords with surgery (fasciectomy)

    This method makes intuitive sense – if there’s abnormal tissue causing a problem, surely the treatment would be to remove it. This option has been around for a long time, and the techniques have improved over the years.

  • Benefits– Surgery has two advantages over the other options. First, it completely removes the lumps and bumps in your palm, whereas the other options leave them behind. Second, it has the best chance of giving you long-lasting relief – that is, the lowest risk of recurrence of the disease.
  • Downside– This is not a small surgery. The incisions are long and there is a minor risk of bleeding. The recovery can be prolonged – while you can be back at normal every day activities within a week or so, it will be months before you can grip a golf club or lift something heavy.

Cut the cords – needle aponeurotomy

    • In this option, the hand is first numbed with anesthetic, a needle is then inserted through the skin and swept back and forth across the cord to cut it. Then the process is repeated several times along the length of the cord, perforating at multiple locations, like a check in a checkbook. Now the finger is forced straight, which breaks the cord at all these points.

    • Benefits– This is a procedure that can be done in the office, or, at the most, in the surgery center with some mild sedation. The recovery is relatively quick as there are no big incisions on the hand.
    • Downside– This is by far the least effective option. It has the highest risk for the disease returning. It also does not remove any of the lumps or bumps in the palm. Finally, it can only be done in certain areas of the hand, because there is a high risk of injury to a nerve or blood vessel with this technique.

As a result of these issues, needle aponeurotomy is not often recommended, although there are certain situations where it may be a good option.

Dissolve the cords – Xiaflex®

    This is the newest treatment option for Dupuytren’s disease, and has been available only since 2010. Xiaflex is an enzyme called collagenase, which specifically targets the tissues that Dupuytren’s cords are made of. The procedure involves two office visits. At your first visit, the enzyme is injected carefully into the cord at multiple spots along its length. Over the next few days, these areas of the cord are dissolved by the enzyme. On your next visit, 2-7 days later, your hand is numbed with anesthetic, and the fingers are forced open, breaking the cords along their length.

  • Benefits– Since the procedure is done in the office, it is usually a bit simpler for you – there are no risks of surgery, and a relatively quick recovery because there are no incisions. The risk of the disease returning is almost as good as surgery. Although the medication is expensive, it will often be paid for by your insurance.
  • Downside– Unlike surgery, most of the lumps and bumps in your hand will not be removed. A few areas are dissolved away, but most of the areas stay behind.

Other treatment considerations

When Dupuytren’s contractures have been present for a long time, the problem extends to the skin of the palm and the finger joints as well.

Skin that has been contracted for a long time loses its elasticity. So when the contracture is treated (with surgery, or injections, or a needle), and the finger is straightened, you might find that you’re missing some skin. What this means is that you will have an open wound on your hand, usually near one of the creases on the palm or the fingers. This can alarm patients sometimes, but its actually not a problem. The open areas heal quickly and beautifully – in fact, it is a bad idea to stitch them closed, because we want new skin to grow in those areas to replace the skin that has gone missing over the years.

Joints don’t like being stuck in one position – they tend to form scar tissue. If your fingers have been contracted for a long time, the joints underneath may not be willing to straighten even if the Dupuytren’s cords are removed. In some cases, the joint scar tissue can be forced open, but in other cases, a surgery may be required to cut through the scar tissue around the joint.

So what’s the right option for you?

It’s a bit of a personal choice when it comes to choosing between surgery and Xiaflex. Needle aponeurotomy is rarely the best option, although sometimes Dr. Nagarkar might recommend it for a particular area. During your consultation, you will have the opportunity to discuss the details of each procedure with Dr. Nagarkar and to learn more about the pros and cons of each. He may recommend one option or another in your particular case, depending on the exact location of the disease, how much your fingers are contracted, any previous procedures you have had on the hand, and any other problems you may have with the hand.

To meet Dr. Nagarkar in person, schedule your consultation or call us.