Dupuytren's contracture - Treating Dupuytren's contracture

Treatment for Dupuytren's contracture is usually only required if the condition affects the function of your hand. Many cases are mild and don't need to be treated.

The treatment used will largely depend on the severity of the condition. In milder cases that require treatment, non-surgical treatments or a minor procedure called a needle fasciotomy may be recommended.

For more severe cases, surgery is an effective and widely used treatment. The two most common surgical procedures are a fasciectomy and an open fasciotomy.

These treatments are described in more detail below.

Non-surgical treatments

Non-surgical treatment options for Dupuytren's contracture include radiation therapy and a relatively new 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 Dupuytren’s contracture. Radiation therapy aims to prevent or delay the need for surgery.

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

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

It is not known exactly how radiation therapy works, but it is 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 body’s connective tissue).

In one of the studies reviewed by NICE, the symptoms of Dupuytren’s 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 is still being developed as a treatment for Duypuytren’s contracture and it may not be suitable for everyone. If you are 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 fairly new medicine for Dupuytren's contracture 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 return to your doctor 24 hours later, and they will straighten your bent finger and stretch it out for 10 to 20 seconds. This breaks the cord and should help increase the range of movement in your bent finger.

Do not 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.

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

In one study that looked at collagenase clostridium histolyticum, the injections were effective in nearly two-thirds of people treated.

The most common side effects occur around the site of the injection and include swelling, bruising, bleeding and pain. These should improve within a week or two. Less common side effects include feeling sick or dizzy.

As with radiation therapy, collagenase clostridium histolyticum is still a relatively new treatment and the long-term effects 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 is usually performed as an outpatient procedure. This means you will not need to be admitted to hospital. You will be given a local anaesthetic that will 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 your hand or your fingers. The blade or needle will be used to divide the cord under your skin.

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

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

However, the rate of reoccurrence for Dupuytren’s contracture is very high, as many as 60% of people who have a needle fasciotomy experience Dupuytren’s 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 is also a more extensive operation and therefore 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 will 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 is likely that you will 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:

partial fasciectomy – where only the affected connective tissue is removed; this is the most commonly used type of surgery for Dupuytren’s 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 will usually be carried out under general anaesthetic. This means you will 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 is necessary to seal the wound using a skin graft, your surgeon will take a graft from an area of your body that is 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 reoccurrence of Dupuytren’s 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 are listed below:

splitting the skin with the needle during a needle fasciotomy
damage to the nerves supplying sensation to your fingertips – the nerves can be repaired, but it is unlikely the fingers will recover their full sensation
joint stiffness – this can be helped with hand therapy (see recovering from Dupytren’s contracture for more information)
wound failure – the wound or graft failing to heal (more likely to occur if you smoke)
infection of the wound – this will usually be 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 itself within a few months, although sometimes it can be permanent.
finger loss (although this is very unlikely)

Discuss the risks of the surgical procedures used to treat Dupuyten’s contracture with your surgeon.