Dupuytren’s Disease

Mr Mike Hayton
FRCS(Trauma and Orth) FFSEM (UK)
Consultant Orthopaedic Hand Surgeon

Other common names

None

Who does it affect?

Usually males over the age of 40 years, occasionally females.

Why does it occur?

There are a number of risk factors associated with developing Dupuytren's disease. These include amongst others: genetic (inherited), diabetes, excess alcohol intake, epilepsy and/or its treatment. In the vast majority of patients we do not know why they develop the disease, but is probably inherited to some extent.

Symptoms

Thickening and cord like structures develop gradually in the palm and extend into the fingers causing the fingers to roll up into the palm. In the initial stages the nodules can be tender but this usually settles.

Clinical Examination

The disease is usually very easy to diagnose and has a very characteristic appearance. A simple test to try and evaluate the severity of the disease is the "table top test". The patient is asked to place the hand flat on the table. If they are unable to do so then it is likely that disease may need surgery in the future.

Investigations

None

Non-operative treatment

Collagenase enzyme injections 

Occasionally night splinting by a therapist will allow the fingers to straighten. However these are not well-tolerated long term.

In 2012,  a new enzyme injection, called Xiapex was released in the UK to dissolve the Dupuytrens disease. Mike Hayton has been using Xiapex since its UK launch and was the first UK surgeon to use Xiapex outside clinical trials. He remains very pleased with the results. It is performed in the outpatient department. On day 1 the Xiapex enzyme is injected into the Dupuytren disease. In the next few days to suit, the patient returns to the out patient department and, under local anaesthetic, the finger is manipulated straight. The enzyme will have dissolved the Dupuytren disease in that area allowing the finger to become straight.

for more info on Xiapex CLICK HERE

Radiotherapy

Radiotherapy has been used for may years to that Dupuytren's disease. It is particularly common in Germany. The treatment is only indicated for early disease in the palm with no flexion contracture of the fingers. Treatment consists of daily radiotherapy for 5 days followed by a 5 week break and then daily treatment again for 5 days. The risks associated with radiotherapy are redness and dryness of the palms and a theoretical risk of causing a malignancy, although no cases have ever been reported. 

 

Percutaneous needle fasciotomy

This is an outpatient procedure that is performed under local anaesthetic. Once numb the surgeon uses a small needle to cut the diseased cords through a tiny needle hole.

 

Operative treatment

The surgery is performed as a day case procedure under local or general anaesthetic. The surgery takes between 30 and 60 minutes. A tourniquet is not usually used if the procedure is performed wide awake with local anaesthetic.

The surgery is performed through a zigzag type incision in the palm and along the finger. The skin flaps are elevated and great care is taken not to injure nerves and blood vessels to the finger. The Dupuytren's disease removed. Occasionally in more advanced cases a skin graft needs to be placed over the wound. The skin is taken from the forearm or groin (for larger grafts). The tourniquet, if used, is then released and any bleeding controlled. The skin is sutured with absorbable stitches and a bulky dressing is applied with a Plaster of Paris slab for immobilisation.

Skin sutures are usually dissolvable.

Post-operative rehabilitation

The anaesthetic will wear off after approximately 6 hours. Simple analgesia usually controls the pain and should be started before the anaesthetic has worn off. The hand should be elevated as much as possible for the first 5 days to prevent the hand and fingers swelling. My preference is to remove the dressing between 2 and 3 days. The wound is cleaned and redressed with a simple dressing. The skin stitches are usually dissolvable. The therapist will apply a resting night-time splint that should be used at night for 6 months.

 

 Click here to download a pdf on post operative instructions

Return to activities of daily living

It is my advice to keep the wound dry for about 10 days.

Return to driving:

The hand needs to have full control of the steering wheel and left hand the gear stick. It is probable advisable to delay returning to driving for at least 10 days.

Return to work:

Everyone has different work environments.
Returning to heavy manual labour should be prevented for approximately 4 - 6 weeks. Please ask your surgeon for advice on this.

Complications

Overall greater than 95% are happy with the result. However complications can occur.
There are complications specific to Dupuytren's surgery and also general complications associated with hand surgery.

General complications:

 - Infection (Less than 1%)
 - Neuroma (Less than 1%, a coiled painful nerve bundle)
 - Numbness

Chronic regional pain syndrome (1-2% rare reaction to surgery with painful stiff hands- this can occur with any hand surgery from a minor procedure to a complex reconstruction.)

Specific complications:

Recurrence: the disease will always recur, however, most patients have a long lasting result that they are happy with.
Failure to completely straighten the finger (particularly after the 2nd and 3rd time surgery or advanced disease).
Injury to the blood vessels and nerves to the finger (very much less than 1%) may leave one side of the finger numb. If this occurs the wound should be explored and if injured, the nerve repaired.
The skin graft, if used, not healing.

 

Useful links with more information

British Dupuytren's society click here or a European site click   www.dupuytren-online.info 

Hear a BBC Radio 4 interview with Mike Hayton and Dr Mark Porter on Dupuytren's disease

Click on the icon below