Two orthopedic hand surgeons from the University of Rochester Medical Center in Rochester, New York use the example of a 66-year-old man with Dupuytren contracture to look at directions for future research. By asking what is the best treatment for this patient, the authors identified areas where more study is needed. They take a look at the disease itself, the current treatment, and point out where more information could help provide better outcomes.
Dupuytren's contracture is a fairly common disorder of the fingers. 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. Dupuytren's contracture usually affects only the ring and little fingers. The contracture spreads to the joints of the finger, which can become permanently immobilized.
The joints affected most often are the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. The MCP joints are what we usually refer to as the "knuckles." The PIP joints are the middle joints between the knuckles and the joints at the tips of the fingers.
Flexion contractures usually develop at the metacarpophalangeal (MCP) joints first. As the disease spreads from the palm down to the fingers, the proximal interphalangeal (PIP) joints start to be affected as well. The patient loses the ability to extend (straighten) the fingers. For the patient in this case study, the motion limitations made it impossible to reach into his pocket or shake hands. Placing the hand flat on the table was no longer possible.
There are two types of treatment for Dupuytren's contracture: nonsurgical and surgical. The best course of treatment is determined by how far the contractures have advanced. Palmar Fascia Removal (palmar fasciectomy) or release of the diseased cords still remains the standard way to treat advanced Dupuytren's contracture.
Bracing and stretching of the fingers alone have not been proven to help in the long term progression of this condition. Nonsurgical and surgical treatments are to treat the contracture itself. This does not cure the disease. Dupuytren's disease continues to slowly form the bands making recurrence a common problem, although it may be years before the contracture presents itself again.
In trying to decide the best way to treat this particular patient, the surgeons involved in his care took a look at the current evidence. Based on studies published in high quality medical journals, they found that studies using the newer less invasive treatment approaches are limited. Studies comparing the results of one technique to another are needed.
For example, collagenase injections and percutaneous needle fasciotomy are two of the newer (less invasive) methods of treatment used without much data to say which one works better or if either one works well at all. Some surgeons are using external fixation devices to stretch the hand out before doing surgery. At this point, we don't know if that is a good idea or not.
The authors made a list of what they think is needed for future research including:
Studies that address patient satisfaction and value placed on treatment and treatment results. Value could be measured by increased sense of wellness or decreased disability.
How much disability Dupuytren contractures cause and whether or not that disability is altered or changed by treatment. Of course, the effect of the various treatment choices on disability needs to be compared.
Comparison of results for collagenase injection versus limited or partial fasciectomy (removal of the diseased fascia).
A way to reliably and accurately measure contracture so comparisons can be made.
Long-term follow-up to find better ways to provide lasting results without recurrence of the problem.
These surgeons agree with other experts who have reported that patients with contractures of the proximal interphalangeal (PIP) joints seem to have the worst outcomes and highest rates of recurrence. Their treatment of choice for PIP joint contractures is limited fasciectomy over injection therapy. They say until there is evidence that the results are better with the expensive collagenase injection, the money is better spent on surgery.
Reference: Spencer J. Stanbury, MD, and Warren C. Hammert, MD. Dupuytren Contracture. In The Journal of Hand Surgery. December 2011. Vol. 36A. No. 12. Pp. 2038-2040.