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Paths for intervention

If the condition requires intervention, intervention is almost exclusively surgery. If surgery is not possible, an extension splint may be used to assist with straightening the fingers. This type of treatment is also often used prior to surgery to help reduce some complications associated with surgery. Other non-surgical interventions such as radiotherapy, steroids and topical vitamin A have been tried but there is little evidence regarding their effectiveness.

Enzyme injections have shown encouraging results however small sample sizes reduce the generalization of the studies to the wider population – further research is required.

A minimally invasive treatment, known as needle aponeurotomy, was developed by Dr Lermusiaux in Paris and has shown encouraging results for individuals with MCP joint contractures, however less so for PIP joint contractures. The procedure is performed under a local anaesthetic, taking approximately 15-20 minutes. The contracted tissue is transected and/or lengthened by shearing and perforation via a fine needle. This technique is used widely in Europe and Russia and is now being used more in the US.

Surgery

Early surgical intervention is preferable to reduce secondary changes occurring to the joint – particularly the PIP joint. Namely degeneration of the volar plate, tight volar collateral ligament structures, digital fascia attaching to the volar skin and attenuated extensor mechanism over the PIP joint with adherence to the dorsal capsule. This can result in a fixed flexion contracture, or bent finger.

Fasciectomy and dermofasciectomy are the most common surgical techniques used to remove diseased tissue. In combination with this a surgeon may perform a PIP joint release, advancement of flaps or open palm wounds. The incision and wound closure most commonly used in surgery is in a Z formation (Z-plasty) to reduce the risk of further contracture. Surgical intervention is generally indicated when MCPJ contracture exceeds 30º and/or any PIPJ contracture is evident.

Complications

Timing of complication	Common complications
Intra-operative:	Nerve injury (in all PIPJ contractures)
	Digital artery injury (in all PIPJ contractures)
Early post-operative:	Infection (highest complication)
	Haematoma (digits only)
	Neuropraxia
	CRPS Type 1
	Skin slough
Late post-operative:	Tendon tethering
	PIP joint contracture
	DIP joint limited movement
	Scar shortening
	Central slip attenuation
	Recurrence of disease
	Carpal tunnel syndrome

Post surgical intervention procedure

There is conflicting evidence in the literature regarding protocol for post-operative therapeutic intervention for dupuytren’s disease with many different regimes and procedures being used. Most therapists and surgeons use splinting however the design of the splint and the wearing regimes vary greatly. Evans (1997) argued that there is an increase in odema, thereby prolonging the initial inflammatory phase, if aggressive splinting or therapy is used three to five days post-operatively. Saar & Crothaus (2000) and Azad et al (1990) backed this theory up with their findings that applying excessive tension or aggravating tissue within this post-operative period can increase scar formation and the recurrence of the disease is inferred. Gupta et al (1998) discovered changes at a cellular level when shear stress is applied to fibroblasts derived from Dupuytren’s tissue. Many authors agree that tension on the hand should be reduced within the splint 5-7 days post-operatively (Evans et al, 2002 and Mullins, 1999).

While valid points are made within the Evans et al (2002) article there are many limitations that reduce the transferability of the results. Despite the large sample size there was no randomisation into groups with some retrospective aspects and some prospective aspects increasing the potential variance. Changes to surgical techniques, instruments and equipment used over 2 decades would have changed and the 49 different surgeons operating would have again varied the results. The author was not blinded to the study and therefore may affect the outcomes. Also, non-standardised assessments and protocol were used, thereby reducing the reliability and validity.

The article does, however, clearly state the theoretical and pathological reasoning for the benefit of the non-tension applied splint being used initially post-operatively. This is confirmed by a number of other studies.

Authors have shown that non-compliance with splint wearing regime and therapy has resulted in poor outcomes and PIPJ contracture (Mullins, 1999). Rives et al (1992) showed that splinting in extension over a long period of time has a beneficial effect on the PIPJ contracture. Similarly dynamic or serial splinting can gain extension beyond that achieved by surgery (Mullens, 1999 and Saar and Grothaus, 2000).

While there is conflicting evidence regarding the benefits of splinting for MCP contractures, the effect is confirmed where PIP joint is involved, with splinting for 8-12 weeks and an active exercise regime (Saar & Grothaus 2000, Mullins 1999, McGrouther 2005 and McFarlane & McDermid 2002). This is possibly due to secondary changes occurring to the volar plate, ligaments and tendons at the PIPJ (Mee 2007).

Aims of Therapy

•  Maintain extension gained in surgery
•  Protect wound site from infection
•  Minimise odema
•  Regain flexion
•  Encourage tendon gliding
•  Minimise impact of scarring
•  Normalise sensation
•  Regain maximum function and strength

Rehabilitation

•  Begins 3-5 days post-operatively
•  Focus on PIPJ management
•  Odema management including elevation, exercises, coban and odema gloves
•  Splint considerations:
  •  pre-op contracture and extension gained in surgery
  •  PIPJ involvement (if PIPJ involved splinting is priority)
  •  maintain extension gained in surgery
  •  dynamic v’s passive
  •  decrease wound tension 3-5 days (MCP flexion, PIP extension)
  •  gentle tension over an extended period (3-6 months)
•  Exercises – 3-5 days post-op tendon gliding exercises for FDP, FDS & central slip, if long term PIPJ contracture work on intrinsic strengthening/function
•  Scar management – massage, silicone gel, elastomers
•  Sensation – desensitisation, sensory feedback, cortical mapping

References

Dupuytren’s Contracture

Understanding this condition is the most important rehabilitation tool in achieving a successful surgical outcome. At Resolve Hand Therapy we provide up to date and easy to understand patient education sheets for the patients to help them achieve a successful result.

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PO Box 92
Balaclava VIC 3183
Phone: 1300 76 99 80
Email: info@resolvehandtherapy.com.au