Dupuytren’s Contracture is a benign fibroproliferative disease. This disease causes the connective tissue under the skin of the palm to thicken and become fibrous and scar like. The thickened tissue causes the fingers to bend toward the palm. Usually affected are the 4th and 5th fingers.
World -wide prevalence of Dupuytren’s is reported to be 8%. It is very common in Sweden (6% of the older population).
Highest reported rates:
- Africa 17%
- Asia 15%
- Europe 10%
- Americas 2%
Men are 3 to 4 times more likely to be affected than women.
The incidence per 10000 cases by age groups:
- 5 in the group below 50 years old
- 15 in the group 50-59
- 30 in the group 60-69
- 40 in the group 70-79
Although the cause is unknown there are factors associated with the development:
- Genetic factors account for 80% of the cases
- Diabetes Mellitus
- Liver Disease
- Chronic occupational use of vibratory tools
- Increased alcohol consumption
A study of over 30,000 Danish pairs of twins showed that the heritability of Dupuytren’s disease is at least 80%.
Another study among 730 men with Dupuytren’s Disease, there was an increased prevalence of
- Plantar fibromatosis (Ledderhose Disease about 16%)
- Peyronie’s Disease ( 8.8%)
Early Signs of Dupuytren’s
Nodules can be felt under the skin on the palmar surface of the hand. These nodules may or may not be painful to touch. These nodules develop very slowly. As the nodules progress, they stretch into the collagen bands in the area. They then progressively extend up into the ring and 5th fingers. In this early stage of the disease, it may be difficult to place the hand palm down and flat on a table- top. This is called the “table- top sign”. Later stages, the fibrous bands pull the fingers down toward the palm.
Classification and Staging
- 0- no fibrosis or extension deficit
- N- Fibrosis palpable but no extension deficit
- N/1- Fibrosis with extension deficit up to 10 degrees
- 1- Fibrosis with extension deficit up to 45 degrees
- 2- Fibrosis with extension deficit 45-90 degrees
- 3- Fibrosis with extension deficit 90-135 degrees
- 4- Fibrosis with extension deficit 135 and greater
Treatment for Dupuytren’s
Steroid Injections- there are no long- term studies showing effectiveness of steroids. Steroids can cause tendon weakening and rupture also side effects such as increased blood sugar and suppressed immunity.
In 1979, Debeyre described the use of a needle as a substitute for a blade to disrupt the fibrous bands. This method found general acceptance because it is less invasive than surgery and hand function was restored quickly. However, the reoccurrence rate of the disease is about 50% in 5 years.
In 2009, collagenase clostridium histolyticum was introduced as an alternative to surgery in Dupuytren’s cases. The reported overall improvement rate was 64%.
In this method, collagenase is injected into the bands to weaken the fibrotic collagen structure. Then, the fingers are forcibly moved to break the bands.
Side effects of this medicine include tendon rupture of ligament, nerve injury, hypersensitivity reactions including anaphylaxis and increased bleeding.
Collagenase treatment and needle fasciotomy have similar outcomes after 1 year post treatment. In some studies, the collagenase had 8% improved outcomes over needle fasciotomy. However, this treatment has been limited in some countries such as Germany due to the exorbitant cost of this drug. Normal cost in the US is $3300 per injection and a full treatment can be up to 8 injections.
Open surgery is reserved for refractory cases. There are different techniques and anatomic approaches but in relation to the minimally invasive techniques of needle fasciotomy or collagenase, the incidence of complications is much greater for open surgery. In surgery to treat reoccurrences, the incidence of complications rises 10 -fold with nerve injuries in particular.
Radiotherapy is very effective in inhibiting proliferating fibroblasts and can freeze early stages of dupuytren’s and can stabilize later stages.
In early stages, there could be 80% control and a 25% remission. For more pronounced flexion contractures (up to 45%) significantly lower efficacy has been reported.
The down- side of ionizing radiation is the possibilities of mutations and tumors can be triggered. Conservative risk for a middle -aged person will increase the risk of a fatal cancer statistically in their lifespan by 0.02%-0.05%. For younger people the risk can be doubled and for older, it can be halved.
There is no cure for Dupuytren’s Disease but this author was intrigued with the association to Peyronie’s Disease. Both are increased bands of collagen fibrous tissue causing an abnormal deviation of the anatomy. Collagenase is now approved for use in both these diseases. The literature has many studies reporting the efficacy of Platelet Rich Plasma for Peyronie’s but the studies discussing the use of PRP in the early stages of Dupuytren’s are lacking.
Platelet Rich Plasma is an autologous blood concentrate with ability to trigger apotosis of abnormal tissue. PRP can also stimulate macrophage activity to break down the fibrotic areas and start the remodeling process. Platelet Rich Plasma has no side effects and the cost is minimal when compared to other treatments.
Platelet Rich Plasma should be considered in the early stages of Dupuytren’s Contracture.
Juventix Regenerative Medical is an industry leader in the regenerative medical field. Our Platelet Rich Plasma Kits are FDA approved and designed for safety and effectiveness. They are cost effective and very easy to use. Our kits provide consistency of concentrated product when obtained from the same source.
Juventix Regenerative Medical offers a patent pending LED Photo- Activator to activate the platelets and begin the regenerative process. The activation, a critical step in the release of cytokines and growth factors, is accomplished with light and not with the addition of other chemicals such as Calcium Chloride or Thrombin.
Juventix Regenerative Medical supplies a Bio-Incubator that transforms the Platelet Rich Plasma into an Injectable Platelet Rich Fibrin. The PRF, commonly called the “second generation of platelet products, has a broader range of clinical applications while providing outstanding outcomes.
RESTORE, REVIVE, REGENERATE- JUVENTIX REGENERATIVE MEDICAL
Dr. Robert McGrath
- Needle Fasciotomy or Collagenase Injection in the Treatment of Dupuytren’s Contracture: A Retrospective Study
Plast Reconstr Surg Glob Open 2020 Jan; 8(1): e2606 PMID 32095410
Dtsch Arztebl Int 2021 Nov; 118(46): 781-788 PMID 34702442