Successful Treatment for Severe Dupuytren ContractureDupuytren's contracture is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. It occurs most often in middle-aged, white men. This condition is seven times more common in men than women.
The condition commonly first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened.
The contracture spreads to the joints of the finger, which can become permanently immobilized. Flexion contractures usually develop at the metacarpophalangeal (MCP) joints first. The MCP joints are what we usually refer to as the "knuckles." As the disease spreads from the palm down to the fingers, the proximal interphalangeal (PIP) joints start to be affected as well. The PIP joints are the middle joints between the knuckles and the interphalangeal (IP) joints (at the tips of the fingers).
In this study, surgeons from the Philadelphia Hand Center at Thomas Jefferson Medical College report on the effect of a three-part therapy treatment. Patients enrolled included 19 men and two women ranging in age from 37 to 80 years old. All had one or more proximal interphalangeal (PIP) joints stuck in flexion of at least 40 degrees or more. Twenty-two proximal interphalangeal (PIP) joints received one standard collagenase injection followed by manual cord rupture (performed by the surgeon).
Then they were treated by a hand therapist. The hand therapy consisted of wearing a custom-made splint (dorsal hand-based extension orthosis) at night and special exercises delivered and supervised by the therapist but also performed by the patient throughout the day at home. For day use, the hand orthosis was replaced by a smaller, finger splint to hold the PIP joint in full extension (straight).
Results measured by change in finger motion were impressive. Patients went from having severe flexion contractures (range of 40 to 80 degrees) down to zero for some patients (a range from zero to 55 degrees among all 22 fingers). A contracture means the finger is stuck and cannot move. A flexion contracture gives us the clinical picture that the patient's finger is bent by the amount of degrees mentioned and cannot straighten.
The positive results of this study are important for two reasons. First, there is no known "cure" for Dupuytren's disease and second, the proximal interphalangeal (PIP) joint does not respond well to treatment. When the metacarpophalangeal (MCP) joints are primarily involved, treatment has been quite successful.
But with the PIP joints, treatment in the past has not been as successful. This may be because contractures of the PIP joints also affect the collateral ligaments (on each side of the finger joint), the volar plate, and cause adhesions inside the joint. The volar plate is actually a very thick ligament that prevents hyperextension of the joint. This ligamentous structure also reinforces the joint capsule and gives the joint greater stability.
In viewing the results of this treatment compared to other studies utilizing surgery and postoperative splinting, there was an 88 per cent improvement in the patients who received this protocol of collagenase injection, manipulation, splinting, and exercises. This compared to a 44 per cent improvement with surgical intervention and splinting for the same problem.
Despite these good results, the authors warn that problems can develop using collagenase injections. The enzymes in the injection can eat away and dissolve more than just the contracted tissue. Tendons and tendon pulleys may be adversely affected by these effects. The use of only one collagenase injection followed by carefully supervised hand therapy may have made the difference in success rates observed in this group of patients.
More study is needed to clearly identify the mechanism by which collagenase injections work. Topics for future study include: 1) the best way to deliver the injection (i.e., with or without ultrasound guidance), 2) the number of injections needed for optimal results, 3) the length of time for hand therapy to continue, and 4) whether or not this treatment protocol will prevent contracture recurrence.
Terri M. Skirven, BS, et al. The Effect of a Therapy Protocol for Increasing Correction of Severely Contracted Proximal Interphalangeal Joints Caused by Dupuytren Disease and Treated with Collagenase Injection. In The Journal of hand Surgery. April 2013. Vol. 38A. No. 4. Pp. 684-689.
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