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Treatment for Dupuytren Disease is Changing

New understanding of Dupuytren disease is changing the way the condition is treated. Surgery is less common now. Injections to dissolve the cords formed by this condition are becoming a preferred treatment. In this article, two hand surgeons from the Boston area review the causes, treatment, complications of treatment, and prognosis for this problem.

Dupuytren disease is a fairly common disorder of the fingers. It occurs most often in middle-aged, white men. This condition is seven times more common in men than women. With this condition there is an increase in fibroblast density, a complex biochemical and cellular interaction.

The disorder may occur suddenly but more commonly progresses slowly over a period of years. The disease usually doesn't cause symptoms until after the age of 40. There is no cure for the disease and even with treatment recurrence and spread are common.

A brief review of anatomy will help explain what happens. Lying just under the palm of the hand is the palmar fascia, a thin sheet of connective tissue shaped somewhat like a triangle. This fascia covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against them. Dupuytren disease transforms the fascia into shortened cords.

The condition commonly first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened (called contractures). Dupuytren's contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

Most people who develop this condition wonder, "Why me?" There isn't a quick and easy answer to this question but there are some hints along the way. Genetics and gender play significant roles. This condition is seven times more common in men than women.

It is common in men of Scottish, Scandinavian, Irish, or Eastern European ancestry. Researchers agree that genes are not a direct cause of this disease, but predispose people to this condition. If you have a sibling (brother or sister) with this problem, you are at least three times more likely to develop the problem yourself.

Scientists haven't found a specific gene responsible for Dupuytren disease. DNA technology has made it possible to identify quite a few genes involved in regulating the collagen fibers. Some genes are kept from doing their job of breaking down collagen, while others that normally build up collagen are increased.

There are other risk factors including age, trauma, infection, alcohol use, diabetes, and smoking. What these risk factors have in common is narrowing of the small blood vessels in the hand. With narrowing of the microvessels comes a loss of blood supply, release of free radicals, and the formation of the wrong kind of collagen tissue. Free radicals are unstable atoms that have an unpaired electron. They cause tissue and DNA damage by robbing other atoms for electrons, thus forming a chain reaction of more free radicals.

Understanding the cellular events that occur in Dupuytren disease has led to the development of more nonsurgical means of treatment. Surgeons can now perform a procedure called percutaneous fasciotomy (also known as a needle aponeurotomy). A needle is slipped in through the skin and used to cut the contracted cord.

Afterwards, the patient sees a hand therapist who uses splinting and motion exercises to help the patient maintain finger motion. This approach is more successful if used early on. Recurrence rates are high in patients with more severe disease.

Another newer treatment approach to this problem is the injection of collagenase into the diseased cords. Collagenase contains enzymes that go to work breaking down the collagen tissue. The procedure can be done in the physician's office and does not require anesthesia.

The injections can be repeated up to three times over a 30-day period of time. Recurrence rates are unknown at this time but with long-term studies, this information will eventually become available and help guide treatment. Complications reported so far include swelling, bruising, pain, and skin problems. Less often, tendon rupture or complex regional pain syndrome develops.

Surgery is still the treatment of choice for moderate-to-severe contractures and in the case of recurrence. As with any surgical procedure, there is always the risk of complications. Wound infection or delays in healing are the most common. But nerve damage and blood vessel injury are also possible. As mentioned, recurrence after surgery is as high as 50 per cent.

Every effort is made with postoperative hand rehab to prevent failure. The hand therapist helps manage scar tissue, restore motion, and maintain flexibility. Regardless of the treatment approach used, regaining full motion and function of the hand while preventing stiffness is the end-goal.

Reference: Eric M. Black, MD, and Philip E. Blazar, MD. Dupuytren Disease: An Evolving Understanding of an Age-Old Disease. In Journal of the American Academy of Orthopaedic Surgeons. December 2011. Vol. 19. No. 12. Pp. 746-757.

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