Dupuytren’s Contracture: JBJS Summary

JBJS SUMMARY

Hand & Wrist

Dupuytren’s Contracture

By: Chelsea Brown, MD

Published: April 26, 2024

Dupuytren contracture is a pathologic thickening of the palmar fascia leading to flexion contractures of the digits. Myofibroblasts cause excess deposition of poorly organized type-III collagen, replacing normal type-I collagen. Dupuytren contracture has a genetic component, and a positive family history correlates with more aggressive disease. Other risk factors include male sex, diabetes mellitus, smoking, excessive alcohol use, epilepsy, manual labor, and hand trauma.‍^[1]

The clinical presentation begins as palmar nodules with skin thickening and/or pitting. As the disease progresses, painless cords develop in the palm and digits, leading to joint contractures. Although any digit can be affected, the ring and long fingers are the most common.‍^[2]

Early disease without a functional deficit is treated with observation. Nighttime extension splinting and soft-tissue mobilization may improve range of motion.‍^[3] Invasive options are indicated for metacarpophalangeal (MCP) joint contractures of >30° or any proximal interphalangeal (PIP) joint contracture.‍^[4]

In-office interventions such as injection of collagenase and needle aponeurotomy have made a substantial impact on the treatment of Dupuytren contracture. A randomized multicenter trial showed that collagenase injections significantly reduced contractures of affected joints compared to a placebo control.‍^[5] In another study, the short and mid-term improvements in joint range of motion were similar between collagenase and limited fasciectomy,‍^[6] although collagenase may be less effective for PIP joint contractures.

Needle aponeurotomy has shown outcomes similar to those of collagenase treatment, with no difference in contracture correction or 3-year recurrence rates.‍^[7]^,‍^[8] When compared to limited fasciectomy, needle aponeurotomy resulted in higher patient satisfaction but less contracture correction and a higher recurrence rate at 5 years.‍^[9]

Recurrence is common after all Dupuytren contracture treatments, but estimates of recurrence rates range widely. A randomized control trial defining recurrence as >30° of deficit progression showed the 3-year recurrence rate to be 19% after collagenase injection and 47% after needle aponeurotomy.‍^[10] In another randomized control trial, the 3-year rate of recurrence (defined as ≥30° of deficit progression) was 33% after collagenase injection and 43% after needle aponeurotomy.‍^[11]

Ongoing research focuses on modifying the underlying disease process. Perioperative use of tamoxifen to inhibit tumor growth factor (TGF)-β function showed positive effects at 3 months after surgery, but these effects were lost over the 2 years following drug cessation.‍^[12] Injection of a TNF inhibitor into Dupuytren nodules has shown some promise in clinical trials, with downregulation of myofibroblasts, decreased expression of alpha-smooth muscle actin and type-I procollagen, and softening and reduction in the size of the nodules.‍^[13]

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References

[1-4]

Dupuytren contracture Contracture - Current Concepts.

Dutta A, Jayasinghe G, Deore S, Wahed K, Bhan K, Bakti N, Singh B. J Clin Orthop Trauma. 2020 Jul-Aug;11(4):590-596. doi: 10.1016/j.jcot.2020.03.026. Epub 2020 Apr 15. PMID: 32684695; PMCID: PMC7355095.

https://pubmed.ncbi.nlm.nih.gov/32684695/

[5]

Injectable collagenase Clostridium histolyticum: a new nonsurgical treatment for Dupuytren contracture disease.

Gilpin D, Coleman S, Hall S, Houston A, Karrasch J, Jones N. J Hand Surg Am. 2010 Dec;35(12):2027-38.e1. doi: 10.1016/j.jhsa.2010.08.007. PMID: 21134613.

https://pubmed.ncbi.nlm.nih.gov/21134613/

[6]

Efficacy and adverse effects of collagenase use in the treatment of Dupuytren contracture disease.

Sanjuan-Cerveró R, Carrera-Hueso FJ, Vazquez-Ferreiro P, Ramon-Barrios MA. Bone Joint J. 2018;100-B(1):73-80. doi:10.1302/0301-620X.100B1.BJJ-2017-0463.R1

https://pubmed.ncbi.nlm.nih.gov/29305454/

[7, 9]

Treatment of Dupuytren contracture contracture.

Soreide E, Murad MH, Denbeigh JM, et al. Bone Joint J. 2018;100-B(9):1138-1145. doi:10.1302/0301-620X.100B9.BJJ-2017-1194.R2

https://pubmed.ncbi.nlm.nih.gov/30168768/

[8, 11]

Three-year recurrence of Dupuytren contracture contracture after needle fasciotomy and collagenase injection: a two-centre randomized controlled trial.

Scherman P, Jenmalm P, Dahlin LB. Journal of Hand Surgery (European Volume). 2018;43(8):836-840. doi:10.1177/1753193418786947

https://pubmed.ncbi.nlm.nih.gov/30012049/

[10]

Three-Year Recurrence of Dupuytren Contracture after Needle Fasciotomy or Collagenase Injection: A Randomized Controlled Trial.

Jørgensen, Rasmus W. MD, PhD; Jensen, Claus H. MD; Jørring, Stig MD. Plastic and Reconstructive Surgery 151(2):p 365-371, February 2023.

https://pubmed.ncbi.nlm.nih.gov/36342689/

[12]

High-dosage tamoxifen as neoadjuvant treatment in minimally invasive surgery for Dupuytren disease in patients with a strong predisposition toward fibrosis: a randomized controlled trial.

Degreef I, Tejpar S, Sciot R, De Smet L. J Bone Joint Surg [Am]2014;96-A:655–662.

https://www.jbjs.org/reader.php?rsuite_id=1187253&source=The_Journal_of_Bone_and_Joint_Surgery/96/8/655&topics=hw#info

[13]

Anti-tumour necrosis factor therapy for early-stage Dupuytren contracture disease (RIDD): a phase 2b, randomised, double-blind, placebo-controlled trial.

Nanchahal J, Ball C, Rombach I, Williams L, Kenealy N, Dakin H, O'Connor H, Davidson D, Werker P, Dutton SJ, Feldmann M, Lamb SE. Lancet Rheumatol. 2022 Jun;4(6):E407-E416. doi: 10.1016/S2665-9913(22)00093-5. Epub 2022 Apr 29. PMID: 35949922; PMCID: PMC7613263.

https://pubmed.ncbi.nlm.nih.gov/35949922/

Related Images from JBJS

Left: Parts of the palmar and digital fascia that become diseased in Dupuytren contracture. Center: The diseased fascia that is associated with the pretendinous cord. Right: The diseased fascia that is not associated with the pretendinous cord. (Reproduced, with permission, from: McFarlane RM. Patterns of the diseased fascia in the fingers in Dupuytren’s contracture. Displacement of the neurovascular bundle. Plast Reconstr Surg. 1974 Jul;54[1]:31-44.)

Pathogenesis and Treatment of Dupuytren Disease

Riester, Scott; van Wijnen, Andre; Rizzo, Marco; Kakar, Sanjeev

JBJS Rev, 2(4):e2 | Review Article | April 08, 2014

Figs. 1 through 4 A seventy-two-year-old, right-hand-dominant man with history of progressive contracture in both hands. Fig. 1 Photograph illustrating the table-top test, with the patient being unable to lay the hand flat on the table because of contracture.

Injectable Collagenase for the Treatment of Dupuytren Contracture

A Critical Analysis Review

Kam, Check C.; Kaplan, F. Thomas D.

JBJS Rev, 1(2):e5 | Review Article with Critical Analysis Component | December 31, 2013

An intraoperative photograph showing the setup for PNF. The patient’s hand is resting on a separate table, the skin over the cord has been disinfected, and the finger to be treated is firmly extended by the surgeon’s nondominant hand.

Percutaneous Needle Fasciotomy for Dupuytren Contracture

Strömberg, Joakim

JBJS Essent Surg Tech, 9(1):e6 | Subspecialty Procedures | February 13, 2019

A: The normal parts of the fascia that produce the spiral cord (1 = pretendinous band, 2 = spiral band, 3 = lateral digital sheet, and 4 = Grayson ligament). B: The spiral cord, showing medial displacement of the neurovascular bundle. (Reproduced, with permission, from: McFarlane RM. Patterns of the diseased fascia in the fingers in Dupuytren’s contracture. Displacement of the neurovascular bundle. Plast Reconstr Surg. 1974 Jul;54[1]:31-44.)

Pathogenesis and Treatment of Dupuytren Disease

Riester, Scott; van Wijnen, Andre; Rizzo, Marco; Kakar, Sanjeev

JBJS Rev, 2(4):e2 | Review Article | April 08, 2014

Extension lack of the PIP joint before treatment (Fig. 1-A), length discrepancy within 2 weeks of external distraction (Fig. 1-B) and the result after 3 months (Fig. 1-C) and 2 years (Fig. 1-D). PIP = proximal interphalangeal.

Spectacular Accidental Distraction Arthroplasty in Dupuytren Contracture with Good Outcome

A Case Report

Degreef, Ilse; Van Hoecke, Emanuel; Van Nuffel, Maarten

JBJS Case Connect, 12(1):e21.00463 | Case Reports | January 20, 2022

The hand of a patient with Garrod disease, showing the characteristic swelling of the knuckle pads.

Pathogenesis and Treatment of Dupuytren Disease

Riester, Scott; van Wijnen, Andre; Rizzo, Marco; Kakar, Sanjeev

JBJS Rev, 2(4):e2 | Review Article | April 08, 2014

Patient case 1. On the left side is an unlabeled intraoperative image showing the Y morphology of the pretendinous cord coalescing to form radial and ulnar-sided spiral nerves. On the right side is a labeled image showing the pathologic cord (“CORD”) and the common digital nerve (CDN) on both sides as it travels distally and spirals volarly and then dorsally to the separate limbs of the Y-shaped cord. The open circles represent the visible course of the nerve, and the dark circles identify the blind course of the nerve as it passes dorsal to the cord and emerge as the radial digital nerve (RDN) and ulnar digital nerve (UDN) on their respective sides.

The “Y” Double Spiral Cord: An Anatomic Variant of Dupuytren Disease

A Report of 2 Cases

Hubbard, James; Li, Sean S.; Chauhan, Aakash; Abrams, Reid

JBJS Case Connect, 11(2):e20.00793 | Case Reports | May 12, 2021

Photographs of the hands, made sixteen months after collagenase injection in the right small finger and the left ring finger, with maintenance of full correction of contracture.

Injectable Collagenase for the Treatment of Dupuytren Contracture

A Critical Analysis Review

Kam, Check C.; Kaplan, F. Thomas D.

JBJS Rev, 1(2):e5 | Review Article with Critical Analysis Component | December 31, 2013

Figs. 3-A through 3-I Schematic and detailed sequential illustration of PNF. FDS = flexor digitorum superficialis, and FDP = flexor digitorum profundus. Figs. 3-A and 3-B Administration of anesthesia. Inject a small volume subcutaneously volar to the cord.

Percutaneous Needle Fasciotomy for Dupuytren Contracture

Strömberg, Joakim

JBJS Essent Surg Tech, 9(1):e6 | Subspecialty Procedures | February 13, 2019

Figs. 4-A through 4-D An illustration of a joint contraction secondary to a Dupuytren contracture, and its correction over time. Fig. 4-A The maximum active extension in a patient with a severe MCP contracture before PNF. Fig. 4-B The maximum active extension immediately after PNF. Fig. 4-C The maximum passive extension at the same time. Fig. 4-D To overcome these secondary changes to the joint, the patient was provided with a night splint for 3 months. The photograph shows the active extension 1 year after PNF.

Percutaneous Needle Fasciotomy for Dupuytren Contracture

Strömberg, Joakim

JBJS Essent Surg Tech, 9(1):e6 | Subspecialty Procedures | February 13, 2019