Trip Answers

Question answered:15/02/07 Warning! this question is over two years old.

An article by Townley et al on Dupuytren’s disease, published in the BMJ in 2006, states:

 

“Most patients with Dupuytren's disease do not need treatment and can be managed expectantly. Intervention is almost exclusively surgical and should be considered when function is impeded or deformity is disabling. All patients must be assessed on an individual basis and the nature of the disability characterised, especially noting use of hands at work and home. Referral to a specialist is advisable when contracture develops. The longer the deformity prevails, the greater the chance of joint contracture becoming irreversible as ligaments remodel in the contracted position. This is especially true of proximal interphalangeal joint contracture, and the first sign of such contracture should precipitate referral to a hand surgeon.” [1]

 

Lee and Baytion writing in the online medical encyclopaedia, e-Medicine discuss criteria and timing of surgery:

 

“Although the option for surgery is considered on a case-by-case basis, guidelines for the timing of surgery exist. In general, surgery should be performed on an affected MCP joint if the contracture is 30° or greater. Such contractures most likely cause some debilitation for the patient…”

 

“The evaluation of a PIP joint is different from that of an MCP joint, and the prognoses differ as well. In the instance of PIP joint contracture, one should clearly define the method to be used in surgery. One should also discuss with the patient his or her expectations, occupation, and activities that may require use of the hands. Fasciectomy is indicated for any amount of PIP joint contracture given the difficulty of correcting severe disease.”

 

Concerning complications, Lee and Baytion note:

 

“Complications occur most often in patients who require extensive fasciectomy due to severe disease. McFarlane and McGrouther report a complication rate as high as 17-19%...” [2]

 

Foye and Stitik give similar information in a second e-Medicine article:

 

“The presence of the disease does not constitute an indication for operation. This depends on the severity of the contracture and the joint involved…

 

- MP flexion contracture of 30° is a universally accepted criterion for surgical correction. At this point, the finger starts getting in the way. Correction of MP flexion contractures is never urgent. The expectations of full and final correction are good for flexion contractures of up to 60°.
- PIP flexion contractures need to be addressed early. The patient is best advised to have an operation as soon as the contracture appears. Complete correction is less common and recurrence is likely. Therefore, PIP flexion contracture constitutes an indication for operation.
- Correction of thumb deformities usually can wait for deformities to develop elsewhere in the hand.” [3]

 

A search in the Medline database identified two studies fewer complications seem to result in cases of less initial deformities:

 

Dias and Braybrooke followed up 1177 patients who had undergone surgery for Dupuytren’s contracture reporting that, “Surgery for Dupuytren's contracture achieved a high rate of full, or almost full, correction in 826 patients (75%) but had a high incidence of post-operative patient-reported complications of 46%. A higher complication rate was seen in those patients with worse initial deformities. The rate of contracture recurrence or persistence was 158 of 1037 (15%)”. [4]

 

Bulstrode et al writing in the ‘Journal of Hand Surgery’ evaluated the complication rate in 253 patients following surgery using a modified Skoog’s technique in the correction of Dupuytren’s contracture.

 

“Complications occurred in 46 patients. Thirty-five patients had 1 complication and 11 patients had more than 1 complication. Intraoperative complications included 6 patients with nerve injury and 1 patient with an arterial injury. Early postoperative complications before wound healing included 5 patients with digital hematoma, 24 patients with wound infection, 6 patients with sympathetic dystrophy, and 6 patients with skin slough. Late postoperative complications included 3 patients with scar contraction and 2 patients with carpal tunnel syndrome. There were 3 non-hand-related complications: 1 urinary retention, 1 left ventricular failure, and 1 myocardial infarction. Recurrence of Dupuytren's disease occurred in 23 of 75 patients after a mean follow-up period of 9.4 years. CONCLUSIONS: The complication rate increased with the severity of disease particularly if the proximal interphalangeal joint contracture was 60 degrees or more. There was no difference in the complication rate for patients who had surgery for primary or recurrent disease.” [5]

 

References

1. Townley WA, Baker R, Sheppard N et al. Dupuytren's contracture unfolded. 1: BMJ. 2006 Feb 18;332(7538):397-400. (http://www.bmj.com/cgi/content/full/332/7538/397). Please note full access to this article is available only with an ATHENS account.
2. Lee S and Baytion M. Dupuytren contracture. E-Medicine. December 2006. (http://www.emedicine.com/orthoped/topic81.htm).
3. Foye P and Stitik T. Dupuytren contracture. E-Medicine. November 2006. (http://www.emedicine.com/pmr/topic42.htm#section~treatment)
4. Dias JJ and  Braybrooke J. . Dupuytren's contracture: an audit of the outcomes of surgery.J Hand Surg [Br]. 2006 Oct;31(5):514-21. Epub 2006 Jul 11. (http://www.hubmed.org/display.cgi?uids=16837113).
5. Bulstrode NW, Jemec B, Smith PJ. The complications of Dupuytren's contracture surgery. J Hand Surg [Am]. 2005 Sep;30(5):1021-5. (http://www.hubmed.org/display.cgi?uids=16182062).

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