Dupuytren's Disease

History
Dupuytren's disease is a disease of the fibrous tissue in the palm of the hand.  It was named after Baron Guillaume Dupuytren, appointed head surgeon at the Hotel-Dieu in Paris in 1815.  He was the youngest man to obtain this title, at the age of 38.  Although his name is now inextricably linked to the disease, there are earlier descriptions of conditions that we believe to be Dupuytren's disease, by Felix Plater of Basel (1614) and Henry Cline in London (1777).

Anatomy
The hand has two skeletons.  One is the bony skeleton, that one would see on an xray.  The other is a fibrous skeleton, that keeps the soft tissues in position.  This layer is normally thin and inert and has very few cells.  In Dupuytren's disease the layer becomes thickened and contractile.  This means that lumps develop and the fingers may bend.

Causes
We believe that Dupuytren's disease has primarily a genetic basis.  That is, one inherits the genes that predispose to Dupuytren's and then some further trigger sets the disease off.  We do not know for certain what are these triggers. There appears to be a link with excess alcohol consumption and with diabetes.

What are the symptoms?
Dupuytren's disease is normally painless.  The first sign is a thickening in the palm, or perhaps a small pit in the skin.  This is commoner in the ring finger.  The disease may then progress and thicker lumps develop, followed by the fingers bending. It is important to note that the disease progression is not smooth - it may stop at any time, or progress rapidly after an indolent period.

Does Dupuytren's occur anywhere other than in the hand?
Sometimes lumps may appear over the back of the PIP joints (the middle joint of the fingers).  These are known as Garrod's pads.  They may also appear in the feet.

What treatment is available?
As Dupuytren's is not a life threatening disease treatment is rarely essential.
If the contracture is mild, no treatment is necessary or indicated.
If the contracture is more severe the bend in the fingers may prove inconvenient, and treatment may be contemplated.
Unfortunately there is no easy treatment for Dupuytren's disase.  We currently rely on two main strands.  

Collagenase
Collagenase is an artificially synthesised enzyme that weakens the collagen in Dupuytren's.  It was launched in the UK on 1 April 2011 under the trade name of Xiapex®.  
Collagenase treatment is not suitable for all types of Dupuytren's disease.  In patients with relatively simple disease its use may avoid the need for surgery.  The collagenase is injected into the diseased cord and 24 to 48 hours later the cord is stretched.  The drug has been carefully tested and the results to date are promising.  Certainly our experience has been satisfying in well chosen cases.
An example of this is given in the following photographs:

What is the rehab after collagenase?
You can start to use the hand normally immediately.  You will be given a splint to wear at night.

Further information

Further information is available on the Xiapex website.  Please note that this is provided by Sobi, the distributors.

Surgery
Sometimes the disease will be too advanced for collagenase and surgery may then be considered.  The surgery may take the form of a simple fasciotomy (a nick in the cord with a knife or a needle).  If the disease is more extensive a larger incision may be necessary.  In young patients or in patients with recurrent disease there is some evidence that applying a skin graft can help to reduce the risk of recurrence.

What are the risks of surgery?
As with all surgery there are some risks involved.  The standard risks are of anaesthetic problems, infection, nerve and artery injury and abnormal pain response.  It is not possible to guarantee full correction and the disease may recur and progress.

What is the rehab?
We usually apply a plaster cast post op, but this is soon replaced by a splint.  We advise that this is worn at night for 6 months to minimise the risk of recurrent contracture.