April 2, 2020

Improving Patient Outcomes for Dupuytren’s Contracture

By Nicholas A. Smerlis, MD, FAAOS, CASQH

 

Around 15 million Americans ages 35 and older are diagnosed with Dupuytren’s contracture, the most common heritable disease affecting connective tissues. Primarily known as a progressive hand deformity, Dupuytren’s contracture is associated with diabetes, hyperlipidemia, alcoholism, and a variety of other medical conditions. Progressive Dupuytren’s contracture can interfere with hand function, making it challenging to perform everyday tasks.  

With no known cause, Dupuytren’s contracture can be a puzzling and often frustrating condition to treat. Reoccurrence is common, and complications can result depending on the state of deformity. As the disease progression is slow and unpredictable, identifying signs and symptoms early on can improve patient outcomes and reduce the need for extensive surgical intervention. In patients younger than 50, progression is sometimes faster. Smoking and high alcohol intake increase the risk of the disease. Evidence also suggests a higher prevalence among patients of Northern European descent, which is where the nickname “Viking’s disease” originated. 

Typically developing over a period of years, the earliest manifestation of Dupuytren’s contracture is a painless nodule on the palm. This disease can be distinguished from other hand contractures because it starts as a nodule and progresses to a contracture of the fingers. 

The degree of contracture affects hand function and influences treatment. In mild cases, the hand still functions well and observation is appropriate. In fact, the initial nodule does not need surgery and does not imply that the disease will progress. When hand function is compromised, however, the finger(s) may need to be straightened.

Two types of approaches to Dupuytren’s contracture may be considered depending on the stage and pattern of the disease. A fasciotomy cuts the cord like a rope, while a fasciectomy removes the cord and associated nodules from the palm and/or fingers. The goal of both is to straighten the finger to improve hand function.  

A fasciotomy can be performed by different techniques: open, needle, or chemical. In the open technique, an incision is placed on the palm in the operating room to expose the cord while protecting the surrounding structures. Both needle and chemical fasciotomies are done in the office. A needle release requires sweeping the tip of the needle back and forth across the cord to divide the abnormal fascia, whereas a chemical fasciotomy relies on dissolving an area of the cord to straighten the finger.

Conversely, a fasciectomy involves an incision in the operating room spanning the length of the cord, and it sometimes requires skin grafts to close wounds. This technique improves the ability to straighten the fingers and shows a lower risk of recurrence at the expense of greater recovery and complications.

Nicholas A. Smerlis, MD, FAAOS, CAQSH is a fellowship trained, Board certified orthopedic hand surgeon specializing in the surgical and non-surgical treatment of the hand, wrist, and elbow. He practices at TPMG Orthopedics in Newport News and Williamsburg. mytpmg.com