Dupuytren's contracture, or palmar fibromatosis, is a benign proliferative of palmar aponeurosis. This condition produces nodules and fibrous cords that determine severe limitation of extension of one or more digits.
The cause is unknown, however several risk factors has been identified: micro-traumatisms, diabetes, diabetes, epilepsy, chronic obstructive pulmonary disease and familiarity. This condition leads gradually to a severe limitation in daily life. It is common belief that the surgical indication should be reserved to those patients that are not able to have simultaneously digits and palm on a table top).
The procedure
Dupuytren’s contracture could be treated with two different procedures:
- Enzymatic treatment with collagenase.
- Surgical treatment
These procedures have different indications, advantages and disadvantages that should be evaluated and discussed with the patient.
Collagenase
Recent technique, based on an enzyme that is injected directly in the cord. This enzyme is able to "dissolve" selectively the fibrous tissue that produce the cord. This procedure lasts few minutes, requires no hospitalization and it could be repeated.
This procedure is performed in two stages:
- Stage 1: enzyme injection. This phase lasts 10 minutes and it is performed under topical anesthesia. A light hand dressing is applied for the following 24 hours. In this span of time the hand should not be used.
- Stage 2: 24 hours after the injection of the enzyme, the practitioner performs an extension maneuver of the treated segment. This procedure breaks the cord already lysed by the enzyme. Small skin bruising and tears could appear in rare cases, usually healing spontaneously in 7-10 days. The patient could resume his/her daily activities in 24 hours, while sports and intense physical efforts are allowed after 7-14 days
Advantages of the enzymatic approach are the fast recovery (a week in most cases), the outpatient procedure and the possibility to repeat the treatment in case of relapse.
Disadvantage is the recurrence rate that can reach 50% in 5 years, along with the impossibility to treat severe cases with more than 2 digits affected.
Surgery
The surgical procedure is able to remove in bulk the affected palmar aponeurosis. The procedure is performed under plexus anesthesia and requires hospitalization.
Surgery lasts approximately 60-80 minutes depending on the degree and the number of affected segments. In most severe cases the skin could be involved by disease and should therefore be removed (generally not more than square centimeter). In this case, a full thickness graft from the forearm is employed to reconstruct this area.
The wound usually heals in 3-4 weeks. Rehabilitation should begin 2 weeks after surgery.
Benefits of the surgical approach are the possibility to treat severe cases, even with more than one affected segments with low rates of relapse.
Disadvantage are the need of hospitalization and the slow recovery.