Brought to you by Dupuytrens Center of Idaho, expert(s) at Dupuytrens Contracture.

Dupuytren's Disease (Morbus Dupuytren)

Morbus Dupuytren (MD) is a benign thickening of the palm's deep connective tissue (fascia). The disease is also known as Dupuytren's contracture or palmar aponeurosis, but we prefer the term Dupuytren's disease, because contraction appears only in a later stage of the disease.

Though more than 170 years have passed since 1832, when Baron Guillaume Dupuytren (1777-1835) presented his findings in Paris on the disease that acquired his name, the root causes still remain unknown.

The disease typically starts on the hand's palm with a little nodule, or several nodules, that can be felt and are initially not very hard. The next stage is the development of cords along tendons. In most cases, initially the tendons of the fourth or fifth finger are affected, but nodules can also appear throughout the palm and sometimes even in the digits. Typically, the disease tends to stabilize temporarily, but the nodules and cords start growing again in degrees over several years. Eventually, as the cords grow thicker, the contractive forces increase and bend the affected fingers towards the palm. Dupuytren's disease typically starts at the ages of 30 to 40, though even children have been reported to suffer from it. For Germany, it is estimated that probably 20 percent of the male population over the age of 50 suffer from Dupuytren, while 40 percent over the age of 80 suffer from this disease. In absolute terms, this amounts to a lot: in Germany alone, the number of sufferers is estimated to be up to 1.9 million people (though such estimates are difficult to verify).

The onset of Dupuytren is typically earlier for males, with men at the ages of 30 - 40 acquiring it two to eight times more often than women. Above the age of 80, the probability is about even. MD is frequent in Middle and Northern Europe, in Australia and in North America. It is far less frequent in Africa and Asia, though recently, Dupyutren patients have been reported in Japan and China. Additionaly, the percentage increases with age. In the USA, it is estimated that approximately 25 percent of middle-aged or elderly individuals develop palmar or plantar contracture. After their initial growth, the small nodules or cords typically keep their size for about five to six years. Then the contraction process starts to bend the fingers. It is usually only at this late stage that patients start to seriously consider an efficient therapy (e.g. surgery). It is less known if radiotherapy is highly efficient in early stages of the disease.

Potential conflict withglucosamine / chondroitin

Some people, specifically when in their middle years, take glucosamine and chondroitin to build up new collagen in their joints and reduce inflammation. We cannot judge the effectiveness of these supplements for recovering joints or for relieving osteoporosis, but occasionally, Dupuytren patients report that taking glucosamine/chondroitin triggered quick growth of Dupuytren nodules, and stopping it reduced those nodules. So, if you suffer from Dupuytren, it might make sense to watch out for accelerated growth of the nodules, in case you are taking glucosamine.

Dupuytren surgery

Surgery is the most common treatment of Dupuytren's disease. Surgery is usually considered at a relatively late stage of the disease, typically when fingers are already bent by more than 15 to 20 degrees and the use of the hand has become restricted. In a very progressed stage, when the hand is already bent inwards, surgery is the only proven therapy that we know of that can make your hand straight again.

Needle aponevrotomy (NA) is an alternative to surgery and is typically applied in an earlier stage and before surgery.

Though radiotherapy may still help to some extent even in late stages, the probability that it will cure for the long term is much higher in initial stages of Dupuytren, and it cannot get a bent hand straight again.

Positive results of surgery

If the operation is well performed and no complications arise, the formerly bent fingers can typically be straightened, and the hand becomes functional again. This is a tremendous improvement in cases where the patients already had a claw-like hand, and now can use their hand again. Yet before undergoing an operation, you should be aware of possible side effects. We encourage you to discuss those with your doctor and consider them thoroughly before undergoing surgery.

Research on hand surgery

There is a lot of research about hand surgery. Therefore, you might have a look at the American Foundation for Surgery of the Hand, its Journal of Hand Surgery or www.journalofsurgicalresearch.com.

Needle Aponevrotomy

Needle Aponevrotomy, also called needle aponeurotomy or needle fasciotomy, and often abbreviated as NA, is a minimal invasive technique originally developed in France more than 20 years ago. The aim of NA is to make bent fingers functional again by straightening them and achieve minimal side effects. The technique uses needles to puncture the contracting cord and thus weaken it until it can be broken by mechanical force, typically with a characteristic snap. NA (needle aponeurotomy) is a non-surgical, ambulant, outpatient procedure.

Positive results of NA

NA/needle aponeurotomy has gained high popularity in France and in the US. The reason is that it usually succeeds in getting bent fingers straight and functional again, takes very little time to apply, requires only local anesthesia, creates no scarring, is considerably less expensive than surgery, can be repeated and is typically fairly painless.

There are currently seven doctors with formal European training of NA in the United States, including Dr. David Kline in Boise.

Common Questions

Here's the answer to some common questions held by many prospective patients.

What can a therapist do to help?

For a severe problem, a therapist may be able to make a custom splint or brace to stretch the fingers out a little more straight. If surgery can't be done, this may help regain some movement of the fingers, but requires using the splint every day. This type of program may also help right before surgery, to make the surgery less complicated and more safe.

After surgery, a therapy program of massage, wound care, exercises and night time splinting is important to get the best possible result and prevent recurrence. It is often helpful to wear a splint while sleeping for several months after surgery.

What can a doctor do to help?

Confirm that this indeed is the problem with your hand. Dupuytren's is sometimes confused with Trigger finger, which can result in bent fingers, but is an entirely different process.

Prescribe therapy as above.

Perform surgery to remove the abnormal tissue, usually through zig-zag cuts in the palm. Surgery may require skin grafts or other tricks to correct the tightness of the skin of the palm. Surgery is usually recommended to help straighten out bent fingers rather than to prevent the fingers from becoming bent. A variation of surgery is a minimally invasive procedure referred to as a Needle Aponeurotomy. In this procedure, the abnormal tissue is weakened using a small needle in the palm. Needle Aponeurotomy is most effective for disease in the palm of the hand, but can be used in certain cases of finger contractures.

A variety of medications have been tried over the years, including colchicine, verapamil, cortisone and collagenase (FDA approval pending), but a medical cure is not yet available.

How successful is treatment?

It depends on how bad the problem is, as well as the person's age, sex, and other medical problems. Most people who have had surgery for Dupuytren's feel that they made the right choice to have surgery.

Taking all comers, most people who have surgery for Dupuytren's contracture will have similar problems later on - either developing elsewhere in the hand or coming back in the area of previous surgery. Dupuytren's is a chronic, recurrent disease.

What happens if you have no treatment?

It's unpredictable, but it generally does not get better on its own.

Some people will notice a lump or a line of tightness in the skin of the palm, and never develop a worse problem - probably best to leave alone. Others will have a progressive bending of their fingers. For example, people who first notice the problem in their forties are likely to have more trouble overall than those whose problem first show up in their seventies - in terms of how badly the fingers curl, how likely the problem is to recur after surgery, and so on.

The longer joints have been bent before surgery and the more bent they are before surgery, the less chance that surgery will get them fully straight.

Information provided by Dupuytren Society