Treating Dupuytren's contracture

Treatment for Dupuytren's contracture (Dupuytren's disease) is usually only required ifthe condition affects the function of your hand. Many cases are mild anddon't need to betreated.

The treatment used largely depends on the severity of the condition. In milder cases thatrequire treatment, non-surgical treatments or a minor procedure called aneedle fasciotomy may be recommended.

Formore severe cases, surgery is an effective and widely used treatment. The two most common surgical proceduresare an open fasciotomy and a fasciectomy.

These treatments are described in more detail below.

Non-surgical treatments

Non-surgical treatment options for Dupuytren's contracture may include radiation therapy and a medicine called collagenase clostridium histolyticum. These are generally most effective if used before the condition becomes severe.

Radiation therapy

In 2010, the National Institute for Health and Care Excellence (NICE) issued guidance about the use of radiation therapy to treat Dupuytrens contracture . Radiation therapy aims to prevent or delay the need for surgery.

Radiation therapy involves aimingcontrolled doses of high-energy radiation (usually X-rays) at the nodules and cords in your hand.

The radiation doses arespread over several consecutive days. After a few weeks, the treatment can be repeated, if necessary.

It's not known exactly how radiation therapy works, but it's thought the radiation affects the development and growth rate of fibroblasts in your hand. Fibroblasts are cells that produce and release collagen (the protein that forms the main part of the bodys connective tissue).

In one of the studies reviewed by NICE, the symptoms of Dupuytrens contracture had improved in over half of the hands that were treated after one year. In another long-term study, two-thirds of people had some degree of symptom relief after 13 years.

Possible side effects of radiation therapy include dry skin, flaky skin and slight thinning of the skin.

Radiation therapy may not be suitable for everyone with Dupuytren's contracture. If you're offered radiation therapy, you should be aware of the uncertainty about its effectiveness and the possible although very small long-term risk that radiation may cause cancerous tumours.

Collagenase clostridium histolyticum

Collagenase clostridium histolyticum is a medicine that can be injected into cords in the palm of your hand. The medicine contains special proteins that can weaken the cords.

After having the injection, you'll be monitored for around half an hour and then you can go home. You return to your doctor 24 hours later and they'll straighten your bent finger and stretch it out for 10 to 20 seconds. This breaks the cord and should help to increase the range of movement in your bent finger.

Don't attempt to straighten your finger yourself within the first 24 hours, or squeeze or press the cord. Keeping your finger bent encourages the injected medicine to stay in the cord, which is where it needs to be.It alsohelps to keep the hand elevated to reduce swelling and prevent the medication leaking out.

If the first injection isn't effective, you can have up to three injections in the same cord, with one month between each injection.

The most common side effects occur around the site of the injection and include:

• swelling
• itching
• bruising
• discolouration of skin, caused by bleeding
• pain

These should improve within a week or two. Less common side effects include feeling sick or dizzy.

As with radiation therapy, the long-term effects of collagenase clostridium histolyticum are unknown. It may also not be widely available.

Needle fasciotomy

A needle fasciotomy is also known as a needle aponeurotomy or a percutaneous needle fasciotomy (percutaneous means "performed through the skin").

It's usually performed as an outpatient procedure, meaning you won't need to be admitted to hospital. You'll be given a Local anaesthetic to numb your hand without making you lose consciousness.

During the procedure, a sharp blade or a very fine needle will be inserted into the fibrous bands in the palm of yourhand or your fingers. The blade or needle will be used todividethe cord under your skin.

Bydividing the thickened tissue, your surgeon will release the tightness in your hand that's forcing your finger to bend. The benefits of needle fasciotomy include:

• your fingers are less deformed
• you recovermore quicklycompared to more extensive surgery
• it's suitable for people who are unable to have more extensive surgery, such as the very frail or elderly
• it has a low risk of complications(around 1%)

However, the rate of recurrence for Dupuytrens contracture is very high: as many as 60% of people who have a needle fasciotomy experience Dupuytrens contracture again within three to five years.

Open fasciotomy

An open fasciotomy is sometimes used to treat more severe cases of Dupuytren's contracture. The procedure is more effective in the long term than a needle fasciotomy, but it's also a more extensive operation and carries some additional risks (see below).

Like a needle fasciotomy, an open fasciotomy will be carried out as an outpatient procedure under local anaesthetic. The surgeon will make an incision in the skin of your hand, so they can gain access to the connective tissue underneath. They'll then cut the thickened connective tissue to divide it up, allowing you to straighten your fingers.

After the surgery has finished, the cut on your hand is sealed with stitches and a dressing is applied. The recovery time for an open fasciotomy is slightly longer than that of a needle fasciotomy, because the wound will need time to heal.

Following the procedure, it's likely that you'll need to make another appointment to have your stitches removed, and you may be left with a small scar.

Fasciectomy

A fasciectomy involves removing the thickened connective tissue. There are three variations of the procedure:

• regionalfasciectomy where the affected connective tissue is removed through a single, largerincision; this is the most commonly used type of surgery for Dupuytrens contracture
• segmental fasciectomy where one or more small cuts are made in the skin, through which small segments of connective tissue are removed
• dermofasciectomy where the affected connective tissue is removed, along with the overlying skin (which may also be affected by the disease) and the wound is sealed with a skin graft (where healthy skin is removed from another part of the body and used to cover the area of skin loss in your hand)

A fasciectomy is usually carried out under general anaesthetic . This means you'll be unconscious throughout the procedure and unable to feel pain. In some cases, regional anaesthetic may be used. This is where local anaesthetic is injected into the nerves near your neck, to numb your whole arm, but you remain conscious.

During the procedure, an incision will be made in your hand and the affected connective tissue will be removed. If it's necessary to seal the wound using a skin graft, your surgeon will take a graft from an area of your body that's usually covered by clothing, such as your upper arm, the front side of your elbow or your groin.

A fasciectomy is a more extensive operation than a fasciotomy, so the risk of complications is slightly higher, at around 5% (see below). However, the results are longer-lasting. For example, the rate of recurrence of Dupuytrens contracture following dermofasciectomy may be as low as 8%.

Read about plastic surgery techniques for more information on skin grafts.

Surgery risks

If your surgery is complex and extensive, your risk of developing complications will be greater than if you have a more minor procedure.

For needle fasciotomy, the rate of complications is low, at around 1%. For fasciectomy, studies have found complication rates to be higher, from around 5%. Some possible complications include:

• splitting the skin with the needle during a needle fasciotomy
• damage to the nerves supplying sensation to your fingertips the nerves can be repaired, butit's unlikely the fingers will recover their full sensation
• joint stiffness this can be helped with hand therapy (see recovering from Dupuytrens contracture for more information)
• wound failure the wound or graft failing to heal (more likely to occur if you smoke)
• infection of the wound usually treated with antibiotics
• haematoma a blood-filled swelling that forms as the wound heals, usually in the palm; it can be drained to reduce the swelling
• scarring
• complex regional pain syndrome a rare complication that causes the hand to become painful, stiff and swollen after surgery; it usually resolves within a few months, although it cansometimesbe permanent
• finger loss (although this is very unlikely)

Discuss the risks of the surgical procedures used to treat Dupuytrens contracture with your surgeon.

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