Options for severe recontracture: recurrent Dupuytren contracture

The worst and unsolved part of Dupuytren contracture is recontracture after treatment, and then recontracture after retreatment. Most people don't have this problem, but when they do, the most common joint to have this problem is the small (pinky) finger PIP joint - the joint in the middle of the finger.

Recontracture after a minimally invasive treatment is often treated with fasciectomy (the most common open surgery), but what are the options when there is severe recontracture after fasciectomy? There are 3 traditional options recommended by hand surgeons.

1. Dermofasciectomy. This operation involves removing Dupuytren tissue and old scar tissue and replacing the skin of the front (palm) half of the finger with skin graft. It has the best chance of long term control, but has 3 potential problems:

• The complication rate is higher than for fasciectomy, but this is actually because the complication rate goes up with every redo surgery, and dermofasciectomy is often done as the second or third operation. The fewer operations before dermofasciectomy, the better.
• The previously operated finger may have so much scarring of the blood vessels that when the surgeon releases everything and tries to straighten the finger, it may start to cut off the circulation. If that happens, it limits how much improvement the surgery can give.
• PIP joint (the knuckle you use to knock on a door) contractures greater than 60 degrees tend to stretch out the tendons on the back of the knuckle which straighten the joint and at the same time shrink the ligaments on the front side of the joint. These issues are hard to perfectly correct even with surgery: the finger may be brought back to a straight position in the operating room, but relapse over the weeks that follow into a stiff bend, despite everything the surgeon, patient and therapist can do. Frustrating.

2. PIP joint fusion. Fusion (or arthrodesis) is removing the joint and making the two bones grow together to form one bone. It's usually done through a cut on the back of the finger, avoiding the battleground of the previous surgery to reduce the risk of nerve and circulatory injuries. The advantage is that the joint will not contract again. The disadvantage is that the joint won't bend again. Normally, the PIP joint is fused in a partial bend - as bent as it can be without catching on things, which really depends on how bent the next joint back is - the MCP joint (the knuckle you use to punch something). There are 3 issues with this operation:

• There's no perfect angle for a fused PIP - you have to choose between not catching it on things or not making a fist. Some people see fusing the joint bent as not much better than what they already have.
• It shortens the finger quite a bit, because the flesh on the palm side of the finger won't stretch out. It doesn't bring the finger back out to its original length.
• It makes a strange grip, because the joint doesn't bend where it used to.

Amputation. Only a consideration if requested by the patient because they have just had it with the finger and want to move on. If you're not at this point, amputation isn't for you. 

I'll review two newer procedures in the next post. 

Radiation and Dupuytren disease

Radiation treatment of Dupuytren disease has been reported in medical journals since the 1930s. It's difficult to study because Dupuytren disease is so unpredictable and progresses so slowly.

Radiation is primarily recommended to prevent contracture in those who do not yet have contracture. The outcome of any preventative treatment has to be compared to the outcome of no treatment, what's called the natural history of the condition. There's very little data on the natural history of progression from Dupuytren nodules to contractures: only two published studies report specifically on this: 
http://Dupuytrens.org/DupPDFs/2001_Gudmundsson.pdf
http://Dupuytrens.org/DupPDFs/2005_Reilly_1022.pdf
Data from these studies would predict that for people with a Dupuytren nodule but no contracture, one out of ten would eventually see their nodule go away without any treatment and less than two out of one hundred would progress to contracture each year. Many patients with Dupuytren disease never need treatment for Dupuytren contracture.

These numbers are essential to evaluation of the outcome of preventative radiation treatment for Dupuytren disease. Published studies on outcomes of radiation for early Dupuytren disease study report progression rates similar to or greater what was found in the above studies of no treatment.
http://Dupuytrens.org/DupPDFs/2012_Seegenschmeidt.pdf
http://Dupuytrens.org/DupPDFs/2010_Betz.pdf

There's much anecdotal experience that radiation for Dupuytren disease reduces itching, tenderness, firmness of nodules, but, whether this translates to changes in rates of contracture progression - the bigger issue - is unclear. The lack of solid evidence despite many years of experience may have more to do with statistical difficulty studying Dupuytren disease than any lack of effect, but the reality is that available data does not show a strong difference comparing treated versus untreated outcomes. The logic behind radiation for Dupuytren disease is also complicated: the early effects of radiation are helpful for inflammatory, proliferative conditions such as the nodular stage of Dupuytren disease, but late effects stimulate fibrosis - exactly the opposite of what you would want for a fibrotic condition. In addition, Betz reported minor, but chronic issues of skin thinning and peeling in about one third of patients undergoing radiation for Dupuytren disease.

In 2015, doctors simply don't have enough data for an evidence based recommendation regarding radiation as a routine prophylactic treatment to influence the rate of progression of Dupuytren contracture - one way or the other. Ultimately, it's the patient's choice. This choice depends on risk tolerance answering this question: which is more important - doing everything possible, or avoiding treatment which might have complications and no benefit? This is the essential question of consenting to any medical treatment. For some treatments (antibiotics for pneumonia), the answer is straightforward because treatment is very predictably low risk and high yield compared to no treatment. For others, such as radiation for early Dupuytren disease, the answer remains unclear. 

Therametrics: Possible Dupuytren Drugs

Therametrics (http://Therametrics.com)  has a novel approach to therapeutic drug discovery which may fit well with efforts to find a cure for Dupuytren disease. Studying Dupuytren disease is difficult because the biology is amazingly complicated. Many different types of drugs might be helpful - too many for any one person to sort through. It's also difficult because it progresses slowly and unpredictably - not good for testing by trial and error. This is a perfect problem for computer analysis - to sort through millions of scientific publications across many different fields of biology, and find hidden clues to what might work. This is what Therametrics software does - sifts through the internet, cross referencing drugs and biology: http://www.therametrics.com/pages-40-drr.html.

Therametrics has been kind enough to demonstrate some of the power of their tools for the Dupuytren Foundation by running an analysis on possible drugs to treat Dupuytren disease. The goal is to identify existing drugs whose effects overlap those of Dupuytren biology. For example, some drug already available for high blood pressure, baldness, or other conditions might also hold the key to help Dupuytren biology. Rather than reinventing the wheel, this approach finds a whole range of existing wheels. A summary of what they found is available at http://Dupuytrens.org/DupPDFs/TherametricsDupuytren.pdf. Pretty complicated, but very exciting. This is the tipping point between "I wonder if this will do anything?" to "Here's why this should work.". This is a giant leap forward, not just for Dupuytren disease research, but for any condition in need of a better medical treatment.

Dupuytren Foundation Interviews: What research needs to be done?

Hand surgeons answer the question: "What research needs to be done to help people with Dupuytren disease?" https://www.youtube.com/watch?v=cr4dKa37hus&list=PLSEyPqK1WriRbR54v3EBxfXkjCzsYFJuN&index=3

Google Glass and Dupuytren Procedures

A neat use of Google Glass to record procedures for Dupuytren disease:
http://glasshandsurgery.blogspot.com/2014/11/google-glass-used-in-hand-surgery.html
Next step is to miniaturize the view and track down the culprit molecules!

Dupuytren Foundation Matching Gift Opportunity

We will Double your Dupuytren Donation Dollars thru December!

Dupuytren Foundation matching gift details here.

Donate here!. 

Big data editorial

The path to understanding Dupuytren disease is being built on evolving technologies: patient crowdsourcing; genetic analysis; big data. We're not alone. This editorial discusses the impact of big data on medical research:http://www.amjorthopedics.com/uploads/media/ajo043090399.pdf.