Dupuytren’s disease of the hands

The characteristic in Dupuytren’s disease is a finger contracture at the MP or PIP joint or both joints. It is a slowly progressive condition and may often have family history of the same condition.

The patient will not be able to straighten the finger and the usual complaint is that they cannot get gloves on, the poke their eye when washing. They cannot flatten the hand to get into tight spaces such as at work or when getting change out of their pocket.

 

                  
On examination you will feel the palpable nodules or cords. There may be associated nodules over the dorsal aspect of the PIP joint (middle knuckle joint of the fingers) and there may also be Peyronie’s disease or plantar pads of the feet, Ledderhose’s disease, named after German surgeon Georg Ledderhose in 1894.

If there are other areas apart from the hands with fibromatosis (lumpy fibrous tissue under the skin), then the patient has a strong genetic tendency for this condition and it may be more widespread, familial and have a higher recurrence.

What can your GP do? Well the most important thing is for your GP to confirm the diagnosis . Next, is to establish if you are having a problem, but if you have come to see the GP specifically about the hand, then presumably you are. If you have come to see the GP about associated conditions, such as Peyronie’s disease or Ledderhose’s disease then examine the hands and establish if there is a problem there. Beyond that the treatment is within secondary care. There are no effective non-operative treatments in primary care .

You will need to be referred to see a Hand Surgeon when the contracted finger is a nuisance to the patient. Also the patient should be advised to see a hand surgeon if the Hueston table top test is positive.

 


The Hand Surgeon may offer you the standard treatment options which are:-
  • Needle fasciotomy
  • Surgical fasciectomy

Needle fasciotomy is a minimally invasive procedure and can be done as an outpatient under Local Anaesthetic in an operating theatre to minimise the risk of infection. Once you have thad a local anesthetic to numb the part of you hand the surgeon is going to treat, a needle is passed through the diseased area and the band causing contracture of you hand releases and the finger will straighten.

Fasciectomy is a surgical operation to excise a segment of the cord and nodule to correct the contracture. The extent of the incision and the amount of excision is dependant on the severity and involvement of the disease. Mr Miranda uses a minimal technique with smaller but multiple incision (Moermans' technique). Sometimes the palmar wounds are left open if upon straightening the finger, there is inadequate skin to close the wound. This produces less postoperative pain and swelling. It is vital after this kind of operation that the patient has about 4 to 8 weeks of hand therapy on a weekly basis to achieve a good result and most will. Irrespective of the technique there is an average recurrence rate of up to 50% sometime within 10 years.

 

The recurrence rates in published studies are:-
  • needle fasciotomy (50 to 58% with mean follow-up of three to five years)
  • open fasciectomy (12 to 39%, mean follow-up 1.5 to 7.3 years; p = 0.001) which was itself significantly higher than that seen with
  • collagenase injections (10 to 31%, mean follow-up four months to four years)
The NEW treatment for Dupuytren’s disease is collagenase which is only produced by Pfizer so we can call it by its trade name Xiapex. It is composed of two collagenases derived from the bacterium clostridium histiolyticum. The drug trial was published in the New England Journal of Medicine in 2009. In the MCP joint there was a 41 degree improvement in the degree of flexion contracture to a mean of 5 degrees residual. In the PIP joint, there was a mean improvement of 29 degrees with a residual 22 degrees of residual flexion contracture. The diagram from the publication  illustrates this.

 


Click this link to see a video about the injection and the patient's experience.

NOTE FOR GP'S


It is available for private patients only at the moment. If however you have a patient who is considering this, at the very least I recommend a referral to see me and this can be an NHS or private referral to assess the suitability for treatment and also to discuss the treatment options with their risks and benefits. The indication for Xiapex or collagenase remains the same as for surgical treatment which is a contracture that is causing  nuisance.