Treatment Options for Dupuytren's Disease: Tips and Tricks

Abstract

Dupuytren's disease (DD) is a common fibroproliferative condition of the hand.

Methods: Management of DD includes observation, non-operative management, and operative management. Operative treatments include percutaneous needle fasciotomy (PNF), open fasciotomy (OF), Clostridium collagenase histolyticum (CCH) injections, limited fasciectomy (LF) and dermofasciectomy (DF). The various methods of DD treatment are reviewed.

Results: We summarize the highlights of each treatment option as well as the strengths and weaknesses. PNF has an immediate improvement, but a higher recurrence rate, potential problematic skin tears, and rare tendon or nerve complications. Limited fasciectomy removes the thickened, diseased tissue but has a more prolonged recovery and has a higher rate of significant complications. Dermofasciectomy has the highest complication rate, and the lowest recurrence. Also, secondary fasciectomy after a previous dermofasciectomy has an unexpected amputation rate as high as 8%. Collagenase injections require two visits, have an increased number of minor side effects such as skin tears, and have rare but significant side effects such as tendon rupture.

Conclusions: This article gives an overview of different treatment options for DD and each of their strengths and weaknesses and provides procedural tips.

Fig. 1.

Triamcinolone injection for a knuckle pad. A, Dupuytren disease knuckle pad. B, Result after a ¼ cm³ of triamcinolone 40 injection at 1 year.

Fig. 2.

PNF for severe, recurrent Dupuytren contracture. A, Severe stage IV Dupuytren contracture after a previous fasciectomy. B, Result immediately after PNF. C, Result from a single PNF treatment 13 years later.

Fig. 3.

CCH injections for severe, recurrent Dupuytren contracture. A, This patient with severe PIPJ contracture after a previous fasciectomy had an amputation recommended due to the severity of the contracture. Injection markings for CCH in blue. B, After manipulation. C, Extension at 4-year follow-up.

Fig. 4.

Markings for CCH injections into recurrent DD in an amputation stump after distal necrosis developed after a previous LF. Before fasciectomy, the surgeon had advised that PNF with blind poking and the risk of tendon damage with CCH were too dangerous.

Fig. 5.

CCH injections for severe, distal Dupuytren contracture. A, PIPJ of -70 degrees and DIPJ of -50 degrees. Three hand surgeons had stated only LF would work. Small doses of CCH 0.1 mg were placed at the PIPJ and DIPJ. B, Result after this one CCH treatment at 2-year follow-up.

Fig. 6.

Management of skin tear with exposed Dupuytren cord. A, Markings for CCH injections. B, Skin tear with exposed cord treated with sterile setup and excision of the exposed tissue. C, At 7-day follow-up.

Fig. 7.

Treatment with CCH injections in Dupuytren boutonniere deformity. A, Small finger with severe PIPJ flexion contracture and DIPJ hyperextension boutonniere. Markings before collagenase injection. “X” marks indicate injection sites for 0.1 mg, and circular dots indicate injection sites for 0.2 mg of CCH. B, Thirteen-month follow-up with PIPJ extension and DIPJ hyperextension improvement after two volar CCH sessions. There was only one CCH tenotomy injection.

Fig. 8.

Distal enzymatic tenotomy for Dupuytren boutonniere deformity. A, Limited distal flexion and injection site of 0.1 mg CCH tenotomy is marked X. B, Markedly improved extension and flexion of the DIPJ after two volar CCH injection sessions, but only one dorsal tenotomy treatment.

Fig. 9.

Use of touch-up CCH injections years later after a previous LF. A, Initial wide awake LF in 2006. B, Touch-up CCH injections (0.5 mg to little finger, 0.1 mg to ring, and 0.3 mg to middle finger) to the right hand in 2011. C, The same hand in 2020.