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Dupuytren's contracture

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Template:Short description Template:Distinguish Template:Cs1 config Template:Infobox medical condition (new) Dupuytren's contracture (also called Dupuytren's disease, Morbus Dupuytren, Palmar fibromatosis and historically as Viking disease or Celtic hand) is a condition in which one or more fingers become permanently bent in a flexed position.<ref name=GHR2016>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> It is named after Guillaume Dupuytren, who first described the underlying mechanism of action, followed by the first successful operation in 1831 and publication of the results in The Lancet in 1834.<ref name=Hart2005/> It usually begins as small, hard nodules just under the skin of the palm,<ref name= GHR2016/> then worsens over time until the fingers can no longer be fully straightened. While typically not painful, some aching or itching, or pain,<ref name=voncampe/> may be present.<ref name= GHR2016/> The ring finger followed by the little and middle fingers are most commonly affected.<ref name= GHR2016/> It can affect one or both hands.<ref name=":1">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The condition can interfere with activities such as preparing food, writing, putting the hand in a tight pocket, putting on gloves, or shaking hands.<ref name= GHR2016/>

The cause is unknown but might have a genetic component.<ref name=NORD2005>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Risk factors include family history, alcoholism, smoking, thyroid problems, liver disease, diabetes, previous hand trauma, and epilepsy.<ref name=GHR2016/><ref name=NORD2005/> The underlying mechanism involves the formation of abnormal connective tissue within the palmar fascia.<ref name=GHR2016/> Diagnosis is usually based on physical examination.<ref name=NORD2005/> In some cases imaging may be indicated.<ref name=":1"/>

In 2020, the World Health Organization reclassified Dupuytren's (termed palmar-type fibromatosis) as a specific type of tumor in the category of intermediate (locally aggressive) fibroblastic and myofibroblastic tumors.<ref name="pmid33179614">Template:Cite journal</ref>

Initial treatment is typically with cortisone injected into the affected area, occupational therapy, and physical therapy.<ref name= NORD2005/> Among those who worsen, clostridial collagenase injections or surgery may be tried.<ref name=NORD2005/><ref name= Braz2015>Template:Cite journal</ref> Radiation therapy may be used to treat this condition.<ref name=Kad2017>Template:Cite journal</ref> The Royal College of Radiologists (RCR) Faculty of Clinical Oncology concluded that radiotherapy is effective in early stage disease which has progressed within the last 6 to 12 months. The condition may recur at some time after treatment;<ref name=NORD2005/> it can then be treated again. It is easier to treat when the amount of finger bending is more mild.<ref name=":1"/>

It was once believed that Dupuytren's most often occurred in white males over the age of 50<ref name=GHR2016/> and was thought to be rare among Asians and Africans.<ref name=Hart2005/> It sometimes was called "Viking disease," since it was often recorded among those of Nordic descent.<ref name=Hart2005/> In Norway, about 30% of men over 60 years old have the condition, while in the United States about 5% of people are affected at some point in time.<ref name=GHR2016/> In the United Kingdom, about 20% of people over 65 have some form of the disease.<ref name=Hart2005>Template:Cite journal</ref>

More recent and wider studies show the highest prevalence in Africa (17 percent), Asia (15 percent).<ref>Template:Cite journal</ref>

Template:TOCLimit

Signs and symptomsEdit

File:Dupuytren's2010.JPG
Dupuytren's contracture of the right little finger. Arrow marks the area of scarring.

Typically, Dupuytren's contracture first presents as a thickening or nodule in the palm, which initially can be with or without pain.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }} Page last reviewed: 29/05/2015</ref> Later in the disease process, which can be years later,<ref name="google1">Template:Cite book</ref> there is increasing loss of range of motion of the affected finger(s). The earliest sign of a contracture is a triangular "puckering" of the skin of the palm as it passes over the flexor tendon just before the flexor crease of the finger, at the metacarpophalangeal (MCP) joint.Template:Citation needed

File:Late Stage Dupuytren's Contracture.webm
Late stage Dupuytren's contracture upon the left hand affecting the little finger and the ring finger but not the index finger and middle finger

Dupuytren disease is generally considered painless, but can be painful if nerve tissue is involved, although this is not usually discussed in the literature.<ref name=voncampe>Template:Cite journal</ref> The most common finger to be affected is the ring finger; the thumb and index finger are much less often affected.<ref name="Netherlands2">Template:Cite journal</ref> The disease begins in the palm and moves towards the fingers, with the metacarpophalangeal (MCP) joints affected before the proximal interphalangeal (PIP) joints.<ref name="NunnSchreuder2014">Template:Cite journal</ref> The MCP joints at the base of the finger responds much better to treatment and are usually able to fully extend after treatment. Due to anatomic differences in the ligaments and extensor tendons at the PIP joints, they may have some residual flexion. Proper patient education is necessary to set realistic treatment expectation. In Dupuytren's contracture, the palmar fascia within the hand becomes abnormally thick, which can cause the fingers to curl and can impair finger function. The main function of the palmar fascia is to increase grip strength; thus, over time, Dupuytren's contracture decreases a person's ability to hold objects and use the hand in many different activities. Dupuytren's contracture can also be experienced as embarrassing in social situations and can affect quality of life.<ref>Template:Cite journal</ref> People may report pain, aching, and itching with the contractions. Normally, the palmar fascia consists of collagen type I, but in Dupuytren patients, the collagen changes to collagen type III, which is significantly thicker than collagen type I.<ref>Template:Cite journal</ref>

Related conditionsEdit

People with severe involvement often show lumps on the back of their finger joints (called "Garrod's pads", "knuckle pads", or "dorsal Dupuytren nodules"), and lumps in the arch of the feet (plantar fibromatosis or Ledderhose disease).<ref name=GHR2016/> In severe cases, the area where the palm meets the wrist may develop lumps. It is thought the condition Peyronie's disease is related to Dupuytren's contracture.<ref name="ReferenceA">Template:Cite journal</ref>

In one study those with stage 2 of the disease were found to have a slightly increased risk of mortality, especially from cancer.<ref>Template:Cite journal</ref>

Risk factorsEdit

Many risk factors have been suggested or identified:

Non-modifiableEdit

|CitationClass=web }}</ref> Dupuytren's has been called the "Viking disease",<ref name=Hart2005/> though it is also widespread in some Mediterranean countries, e.g., Spain<ref>Template:Cite journal</ref> and Bosnia.<ref>Template:Cite book</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Dupuytren's is uncommon among groups including Chinese and Africans.<ref name=Reykjavik>Template:Cite journal</ref>Template:Clarify

  • In June 2023 a study found that gene variants that were inherited from Neanderthals dramatically increased the odds of developing the condition <ref>{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref>

  • Male sex; men are 80% more likely to develop the condition<ref name=Netherlands2/><ref name="orthoinfo"/><ref name="google2">Template:Cite book</ref>
  • Age of 50 or over (5% to 15% of men in that group in the US); the likelihood of getting Dupuytren's disease increases with age<ref name=Netherlands2/><ref name=Reykjavik/><ref name="google2"/>
  • A family history (60% to 70% of those affected have a genetic predisposition to Dupuytren's contracture)<ref name=Netherlands2/><ref name="urlDupuytrens Contracture - What is Dupuytrens Contracture">{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref>

ModifiableEdit

  • Smoking, especially 25-plus cigarettes per day<ref name=Reykjavik/><ref name=Burge>Template:Cite journal</ref>
  • Lower-than-average body mass index (thinness).<ref name=Reykjavik/>
  • Alcohol consumption<ref name=Hart2005/><ref name=Burge/>
  • Manual work:<ref name=Reykjavik/><ref name="2023-01-12">Template:Cite journal</ref> a 2023 paper by researchers at the University of Groningen Medical Centre and Oxford University, "Dupuytren's disease is a work-related disorder: results of a population-based cohort study", found that people whose jobs involved significant manual work were 1.29 times more likely to develop Dupuytren's disease than others, with a linear dose–response relationship with cumulative manual labour over 30 years.<ref name="2023-01-12"/>

Other conditionsEdit

DiagnosisEdit

TypesEdit

There may be three types of Dupuytren's disease:<ref name=Eaton>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

  • Type 1: An aggressive form of the disease found in only 3% of people with Dupuytren's, which can affect men under 50 with a family history of Dupuytren's. It is often associated with other symptoms such as knuckle pads and Ledderhose disease. This type is sometimes known as Dupuytren's diathesis.<ref name="Hindocha2006"/>
  • Type 2: The more normal type of Dupuytren's disease, usually found in the palm only, and which generally begins above the age of 50. This type may be made more severe by other factors such as diabetes or heavy manual labor.<ref name=Eaton/>
  • Type 3: A mild form of Dupuytren's which is common among diabetics or which may also be caused by certain medications, such as the anti-convulsants taken by people with epilepsy. This type does not lead to full contracture of the fingers, and is probably not inherited.<ref name=Eaton/>

TreatmentEdit

Treatment is indicated when the so-called table-top test is positive. With this test, the person places their hand on a table. If the hand lies completely flat on the table, the test is considered negative. If the hand cannot be placed completely flat on the table, leaving a space between the table and a part of the hand as big as the diameter of a ballpoint pen, the test is considered positive and surgery or other treatment may be indicated. Additionally, finger joints may become fixed and rigid. There are several types of treatment, with some hands needing repeated treatment.Template:Citation needed

The main categories listed by the International Dupuytren Society in order of stage of disease are radiation therapy, needle aponeurotomy (NA), collagenase injection, and hand surgery. Template:As of the evidence on the efficacy of radiation therapy was considered inadequate in quantity and quality, and difficult to interpret because of uncertainty about the natural history of Dupuytren's disease.<ref name=NICE/>

Needle aponeurotomy is most effective for Stages I and II, covering 6–90 degrees of deformation of the finger. However, it is also used at other stages. Collagenase injection is likewise most effective for Stages I and II. However, it is also used at other stages.Template:Citation needed

Hand surgery is effective at stage I to stage IV.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Use of a splint to keep treated fingers straight following various forms of treatment, typically at all times for some days, then at nighttime for some weeks, is usual. However, a 2015 Cochrane review concluded: "low-quality evidence suggests that postoperative splinting may not improve outcomes and may impair outcomes by reducing active flexion. Further trials on this topic are urgently required".<ref name=cochrane/>

SurgeryEdit

On 12 June 1831, Dupuytren performed a surgical procedure on a person with contracture of the fourth and fifth digits who had been previously told by other surgeons that the only remedy was cutting the flexor tendons. He described the condition and the operation in The Lancet in 1834<ref>Template:Cite journal</ref> after presenting it in 1833, and posthumously in 1836 in a French publication by Hôtel-Dieu de Paris.<ref>Template:Cite journal</ref> The procedure he described was a minimally invasive needle procedure.

Because of high recurrence rates,Template:Citation needed new surgical techniques were introduced, such as fasciectomy and then dermofasciectomy. Most of the diseased tissue is removed with these procedures.Template:Clarify span For some individuals, the partial insertion of "K-wires" into either the DIP or PIP joint of the affected digit for a period of a least 21 days to fuse the joint is the only way to halt the disease's progress. After removal of the wires, the joint is fixed into flexion, which is considered preferable to fusion at extension.

Research using large datasets in the UK has shown surgery to be safe and effective. When surgery needs to be repeated, however, the research suggests there are higher risks of serious complications such as finger amputation.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Amputation of fingers may be needed for severe or recurrent cases or after surgical complications.<ref>Template:Cite journal</ref>

Limited fasciectomyEdit

File:Hand Post Dupuytren-Op with Stiches and healed.jpg
Hand immediately after surgery, and completely healed

Limited/selective fasciectomy removes the pathological tissue, and is a common approach.<ref name="HillelD">Template:Cite journal</ref><ref name="MorsiK">Template:Cite journal</ref><ref>Living Textbook of Hand Surgery https://books.publisso.de/en/publisso_gold/publishing/books/overview/49/71</ref> A 2015 Cochrane review reported that low-quality evidence suggested that fasciectomy may be more effective for people with advanced Dupuytren's contractures.<ref name=cochrane>Template:Cite journal</ref>

During the procedure, the person is under regional or general anesthesia. A surgical tourniquet prevents blood flow to the limb.<ref name=RijssenComp>Template:Cite journal</ref> The skin is often opened with a zig-zag incision but straight incisions with or without Z-plasty are also described and may reduce damage to neurovascular bundles.<ref name="Robbins">Template:Cite journal</ref> All diseased cords and fascia are excised.<ref name="HillelD"/><ref name="MorsiK"/><ref name=RijssenComp/> The excision has to be very precise to spare the neurovascular bundles.<ref name=RijssenComp/> Because not all the diseased tissue is visible macroscopically, complete excision is uncertain.<ref name="MorsiK"/>

A 20-year review of surgical complications associated with fasciectomy showed that major complications occurred in 15.7% of cases, including digital nerve injury (3.4%), digital artery injury (2%), infection (2.4%), hematoma (2.1%), and complex regional pain syndrome (5.5%), in addition to minor complications including painful flare reactions in 9.9% of cases and wound healing complications in 22.9% of cases.<ref>Template:Cite journal</ref> After the tissue is removed the incision is closed. In the case of a shortage of skin, the transverse part of the zig-zag incision is left open. Stitches are removed 10 days after surgery.<ref name=RijssenComp/>

After surgery, the hand is wrapped in a light compressive bandage for one week. Flexion and extension of the fingers can start as soon as the anaesthesia has resolved. It is common to experience tingling within the first week after surgery.<ref name=cochrane/> Hand therapy is often recommended.<ref name=RijssenComp/> Approximately six weeks after surgery the patient is able completely to use the hand.<ref name="Ned Tijdschr Geneeskd. 2009;153;A129">Template:Cite journal</ref>

The average recurrence rate is 39% after a fasciectomy after a median interval of about four years.<ref>Template:Cite journal</ref>

Wide-awake fasciectomyEdit

Limited/selective fasciectomy under local anesthesia (LA) with epinephrine but no tourniquet is possible. In 2005, Denkler described the technique.<ref name="Denkler">Template:Cite journal</ref><ref name="Bismil">Template:Cite journal</ref>

DermofasciectomyEdit

Dermofasciectomy is a surgical procedure that may be used when:

  • The skin is clinically involved (pits, tethering, deficiency, etc.)
  • The risk of recurrence is high and the skin appears uninvolved (subclinical skin involvement occurs in ~50% of cases<ref>Template:Cite journal</ref>)
  • Recurrent disease.<ref name="MorsiK"/> Similar to a limited fasciectomy, the dermofasciectomy removes diseased cords, fascia, and the overlying skin.<ref name=pmid10697321>Template:Cite journal</ref>

Typically, the excised skin is replaced with a skin graft, usually full thickness,<ref name="MorsiK"/> consisting of the epidermis and the entire dermis. In most cases the graft is taken from the antecubital fossa (the crease of skin at the elbow joint) or the inner side of the upper arm.<ref name=pmid10697321/><ref name=pmid19258615>Template:Cite journal</ref> This place is chosen because the skin color best matches the palm's skin color. The skin on the inner side of the upper arm is thin and has enough skin to supply a full-thickness graft. The donor site can be closed with a direct suture.<ref name=pmid10697321/>

The graft is sutured to the skin surrounding the wound. For one week the hand is protected with a dressing. The hand and arm are elevated with a sling. The dressing is then removed and careful mobilization can be started, gradually increasing in intensity.<ref name=pmid10697321/> After this procedure the risk of recurrence is minimised,<ref name="MorsiK"/><ref name=pmid10697321/><ref name=pmid19258615/> but Dupuytren's can recur in the skin graft<ref>Template:Cite journal</ref> and complications from surgery may occur.Template:Vague<ref>Template:Cite journal</ref>

Segmental fasciectomy with/without celluloseEdit

Segmental fasciectomy involves excising part(s) of the contracted cord so that it disappears or no longer contracts the finger. It is less invasive than the limited fasciectomy, because not all the diseased tissue is excised and the skin incisions are smaller.<ref name=pmid1960487>Template:Cite journal</ref>

The person is placed under regional anesthesia and a surgical tourniquet is used. The skin is opened with small curved incisions over the diseased tissue. If necessary, incisions are made in the fingers.<ref name=pmid1960487/> Pieces of cord and fascia of approximately one centimeter are excised. The cords are placed under maximum tension while they are cut. A scalpel is used to separate the tissues.<ref name=pmid1960487/> The surgeon keeps removing small parts until the finger can fully extend.<ref name=pmid1960487/><ref name=pmid21682613>Template:Cite journal</ref> The patient is encouraged to start moving their hand the day after surgery.<ref name=pmid1960487/> After surgery people wear a light pressure dressing for four days, followed by an extension splint, typically continuously for a few weeks, then every night for eight weeks.<ref name=pmid21682613/>

The same procedure is used in the segmental fasciectomy with cellulose implant. After the excision and a careful hemostasis, the cellulose implant is placed in a single layer in between the remaining parts of the cord.<ref name=pmid21682613/>

Less invasive treatmentsEdit

Studies have been conducted for percutaneous release, extensive percutaneous aponeurotomy with lipografting and collagenase. These treatments show promise.<ref name=RijssenPerc/><ref name=Hovius>Template:Cite journal</ref><ref name=pmid21127696>Template:Cite journal</ref><ref name=pmid19726771>Template:Cite journal</ref>

Percutaneous needle fasciotomyEdit

Needle aponeurotomy is a minimally-invasive technique where the cords are weakened through the insertion and manipulation of a small needle. It is applicable only if the contracture is clearly visible. The hand is first numbed by injection with local anaesthetic.<ref>Template:Citation</ref> The cord is then sectioned at as many levels as possible in the palm and fingers, depending on the location and extent of the disease, using perhaps a 25-gauge needle mounted on a 10 ml syringe.<ref name=RijssenPerc>Template:Cite journal</ref> Once weakened, the offending cords can be snapped by putting tension on the finger(s) and pulling the finger(s) straight. After the treatment a small dressing is applied for 24 hours, after which people are able to use their hands normally. No splints or physiotherapy are given.<ref name=RijssenPerc/>

The advantage of needle aponeurotomy is the minimal intervention without incision (done in the office under local anesthesia) and the very rapid return to normal activities without need for rehabilitation, but the nodules may resume growing.<ref>Template:Cite journal</ref> A study reported postoperative gain is greater at the MCP joint level than at the level of the IP-joint and found a reoperation rate of 24%; complications are scarce.<ref>Template:Cite journal</ref> Needle aponeurotomy may be performed on fingers that are severely bent (stage IV), and not just in early stages. A 2003 study showed 85% recurrence rate after five years.<ref name=Rijssen5>Template:Cite journal</ref>

A comprehensive review of the results of needle aponeurotomy in 1,013 fingers was performed by Gary M. Pess, MD, Rebecca Pess, DPT, and Rachel Pess, PsyD, and published in the Journal of Hand Surgery April 2012. Minimal follow-up was three years. Metacarpophalangeal joint (MP) contractures were corrected at an average of 99% and proximal interphalangeal joint (PIP) contractures at an average of 89% immediately post procedure. At final follow-up, 72% of the correction was maintained for MP joints and 31% for PIP joints. The difference between the final corrections for MP versus PIP joints was statistically significant. When comparing people aged below and above 55 years of age there was a statistically significant difference at both MP and PIP joints, with greater correction maintained in the older group.Template:Citation needed

Gender differences were not statistically significant. Needle aponeurotomy provided successful correction to 5° or less contracture immediately post procedure in 98% (791) of MP joints and 67% (350) of PIP joints. There was recurrence of 20° or less over the original post-procedure corrected level in 80% (646) of MP joints and 35% (183) of PIP joints. Complications were rare except for skin tears, which occurred in 3.4% (34) of digits. This study showed that NA is a safe procedure that can be performed in an outpatient setting. The complication rate was low, but recurrences were frequent in younger people and for PIP contractures.<ref>Template:Cite journal</ref>

Extensive percutaneous aponeurotomy and lipograftingEdit

A technique introduced in 2011 is extensive percutaneous aponeurotomy with lipografting.<ref name=Hovius/> This procedure also uses a needle to cut the cords. The difference with the percutaneous needle fasciotomy is that the cord is cut at many places. The cord is also separated from the skin to make place for the lipograft that is taken from the abdomen or ipsilateral flank.<ref name=Hovius/> This technique shortens the recovery time. The fat graft results in supple skin.<ref name=Hovius/>

Before the aponeurotomy, a liposuction is done to the abdomen and ipsilateral flank to collect the lipograft.<ref name=Hovius/> The treatment can be performed under regional or general anesthesia. The digits are placed under maximal extension tension using a firm lead hand retractor. The surgeon makes multiple palmar puncture wounds with small nicks. The tension on the cords is crucial, because tight constricting bands are most susceptible to be cut and torn by the small nicks, whereas the relatively loose neurovascular structures are spared. After the cord is completely cut and separated from the skin the lipograft is injected under the skin. A total of about 5 to 10 ml is injected per ray.<ref name=Hovius/>

After the treatment the person wears an extension splint for 5 to 7 days. Thereafter the person returns to normal activities and is advised to use a night splint for up to 20 weeks.<ref name=Hovius/>

CollagenaseEdit

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File:Xiaflex (Collagenase) for Dupuytrens.jpg
Collagenase enzyme injection: before, next day, and two weeks after first treatment

The cords are weakened through the injection of small amounts of the enzyme collagenase, which breaks peptide bonds in collagen.<ref name=pmid21127696/><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name="pmid19726771"/>Template:Excessive citations inline

Clostridial collagenase injections have been found to be more effective than placebo.<ref name=Braz2015/>

In February 2010 the US Food and Drug Administration (FDA) approved injectable collagenase extracted from Clostridium histolyticum for the treatment of Dupuytren's contracture in adults with a palpable Dupuytren's cord. (Three years later, it was approved as well for the treatment of the sometimes related Peyronie's disease.)<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="google1"/> In 2011 its use for the treatment of Dupuytren's contracture was approved as well by the European Medicines Agency, and it received similar approval in Australia in 2013.<ref name="google1"/> However, the Swedish manufacturer withdrew distribution of this drug in Europe<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> including the UK, Australia, and Asia in March 2020.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> (It is also used in the US as a dermatological treatment for cellulite aka "cottage cheese thighs").<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

The treatment with collagenase is different for the MCP joint and the PIP joint. In a MCP joint contracture the needle must be placed at the point of maximum bowstringing of the palpable cord.<ref name=pmid21127696/> The needle is placed vertically on the bowstring. The collagenase is distributed across three injection points.<ref name=pmid21127696/> For the PIP joint the needle must be placed not more than 4 mm distal to palmar digital crease at 2–3 mm depth.<ref name=pmid21127696/> The injection for PIP consists of one injection filled with 0.58 mg CCH 0.20 ml.<ref name=pmid19726771/> The needle must be placed horizontal to the cord and also uses a three-point distribution.<ref name=pmid21127696/> After the injection the person's hand is wrapped in bulky gauze dressing and must be elevated for the rest of the day. After 24 hours the person returns for passive digital extension to rupture the cord. Moderate pressure for 10–20 seconds ruptures the cord.<ref name=pmid21127696/> After the treatment with collagenase the person should use a night splint and perform digital flexion/extension exercises several times per day for 4 months.<ref name=pmid21127696/>

Radiation therapyEdit

File:DupuytrensRadiotherapyHamburg.jpg
Shows the beam's-eye view of the radiotherapy portal on the hand's surface, with the lead shield cut-out placed in the machine's gantry

Radiation therapy has been used mostly for early-stage disease, but is unproven.<ref name=Kad2017/> Evidence to support its use Template:As of, however, was scarce—efforts to gather evidence are complicated due to a poor understanding of how the condition develops over time.<ref name=Kad2017/><ref name=NICE>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> It has been studied in early disease.<ref name=Kad2017/> The Royal College of Radiologists concluded that radiotherapy is effective in early stage disease which has progressed within the last 6 to 12 months.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Alternative medicineEdit

Several alternate therapies such as vitamin E treatment have been studied, though without control groups. Most doctors do not value those treatments.<ref>Proposed Natural Treatments for Dupuytren's Contracture, EBSCO Complementary and Alternative Medicine Review Board, 2 February 2011 Template:Webarchive. Date February 2011.</ref> None of these treatments stops or cures the condition permanently. A 1949 study of vitamin E therapy found that "In twelve of the thirteen patients there was no evidence whatever of any alteration. ... The treatment has been abandoned."<ref>Template:Cite journal</ref><ref>Therapies for Dupuytren's contracture and Ledderhose disease with possibly less benefit, International Dupuytren Society, 19 January 2011 Template:Webarchive.</ref>

Laser treatment (using red and infrared at low power) was informally discussed in 2013 at an International Dupuytren Society forum,<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> as of which time little or no formal evaluation of the techniques had been completed. In 2021 improvement of Dupuytren's disease in a single patient by treatment with a fractionated CO₂ laser was reported.<ref>Template:Cite journal</ref>

Postoperative careEdit

Postoperative care involves hand therapy and splinting. Hand therapy is prescribed to optimize post-surgical function and to prevent joint stiffness. The extent of hand therapy is depending on the patient and the corrective procedure.<ref>Template:Cite journal</ref>

Besides hand therapy, many surgeons advise the use of static or dynamic splints after surgery to maintain finger mobility. The splint is used to provide prolonged stretch to the healing tissues and prevent flexion contractures. Although splinting is a widely used post-operative intervention, evidence of its effectiveness is limited,<ref name=pmid18447898>Template:Cite journal</ref> leading to variation in splinting approaches. Most surgeons use clinical experience to decide whether to splint.<ref name=pmid18644117>Template:Cite journal</ref> Cited advantages include maintenance of finger extension and prevention of new flexion contractures. Cited disadvantages include joint stiffness, prolonged pain, discomfort,<ref name=pmid18644117/> subsequently reduced function and edema.

A third approach emphasizes early self-exercise and stretching.<ref name="Bismil"/>

PrognosisEdit

Dupuytren's disease has a high recurrence rate, especially when a person has so-called Dupuytren's diathesis. The term diathesis relates to certain features of Dupuytren's disease, and indicates an aggressive course of disease.<ref name="Hindocha2006">Template:Cite journal</ref>

The presence of all new Dupuytren's diathesis factors increases the risk of recurrent Dupuytren's disease by 71%, compared with a baseline risk of 23% in people lacking the factors.<ref name="Hindocha2006"/> In another study the prognostic value of diathesis was evaluated. It was concluded that presence of diathesis can predict recurrence and extension.<ref name=pmid15336743>Template:Cite journal</ref> A scoring system was made to evaluate the risk of recurrence and extension, based on the following values: bilateral hand involvement, little-finger surgery, early onset of disease, plantar fibrosis, knuckle pads, and radial side involvement.<ref name=pmid15336743/>

Minimally invasive therapies may precede higher recurrence rates. Recurrence lacks a consensus definition. Furthermore, different standards and measurements follow from the various definitions.Template:Citation needed

Notable casesEdit

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  • Ally McCoist (Born 1962), Scottish footballer<ref>{{#invoke:citation/CS1|citation

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ReferencesEdit

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