The Hip: Preservation, Replacement and Revision

Dupuytren's Contracture 

- See: Surgical Treatment of Dupuytren's:

- Discussion:
    - originally described by Baron Guillaume Dupuytren in 1831;
             - ref: Guillaume Dupuytren: His Life and Surgical Contributions
    - usually appears between age 40 to 60 years;
    - disease occurs more often and is more severe in males or persons of Northern European Origin;
    - may be associated w/ alcoholism, epilepsy (due to medications), and/or diabetes, and has autosomal dominance in some cases;
    - patho-anatomy
            - extracellular matrix-cytoskeletal connections at the surface of the specialized contractile fibroblast (myofibroblast) in Dupuytren disease.
            - Dupuytren's contracture. An electron microscopic, biochemical, and clinical correlative study.
            - The expression of platelet derived growth factor gene in Dupuytren's contracture. RM Terek et al.  JBJS. Vol 77-A. 1995. p 1-9.
  - etiology:
            - associated w/ myofibroblast proliferation & increases in type III collagen and platelet derived growth factor B;
            - immature type 3 collagen is proportionately increased in relation to normally occurring type I collagen within affected palmar fascia;
            - contractile potential of myofibroblasts causes contraction of the collagenous palmar fascia and overlying skin and fingers;
    - prognosis:
            - a more aggressive disease is one that is associated w/:
                    - positive family history;
                    - onset before age 40;
                    - bilateral involvement;
                    - involvement of radial digits;
                    - ectopic disease (feet, penis);

- Clinical Findings:
     - patients may present with a fixed flexion deformities in the MP, PIP, and rarely the DIP joints;
     - occurs most often in the ring and little fingers, and is bilateral in 45%;
     - patho-anatomy
     - vascular:
            - a digital Allen's test may reveal sluggish filling on either side of the affected digit;
     - palm:
            - fibrous nodules appear over pretendinous bands;
            - involvement often begins w/ thickening of pre-tendinous cord over 4th ray;
     - MP joint:
            - mp contracture may be caused by pretendinous cord contracture or by contracture of spiral band;
            - 20 to 30 deg flexion contracture is indication for surgery;
            - abduction may be limited as natatory ligament becomes contracted;
     - PIP joint:
            - central cord is in continuity with pretendinous cord;
            - spiral cord can manifest as an extension of pretendinous cord thru spiral band or at musculotendinous junction of intrinsics;
            - any degree of flexion contracture of pip is indication for surgery;
            - consider whether there is an associated trigger finger;
     - thumb:
            - may show a flexion deformity along w/ a web space contracture;
     - ectopic disease:
Ledderhose Disease
                  - associated fibrosis in feet (5% of patients);
            - Peyronie's disease:
                  - associated fibrosis in penis and knuckle pads (3% of patients);
                  - these pts generally have a higher rate of recurrence;
            - Dorsum of PIP: (knuckle pads);

- Non-Surgical Treatment:
    - Dupuytren's nodules can be injected on a 6 week serial basis w/ 1-3 cc of triamcinolone (40 mg/ml);
          - patients may note a softening and flattening of the nodules over months;
    - clostridial collagenase:
          - injections of 10,000 units into the area of maximal involvement may dissolve the Dupuytren cords;
          - technique is most appropriate for disease limited to the palm and MP joints;
          - results may be seen with in weeks;
          - references:
                - Injectable Collagenase Clostridium Histolyticum for Dupuytren's Contracture
                - Collagen as a clinical target: nonoperative treatment of Dupuytren's disease
                - Partial Improvement of Dupuytren Contracture Following a Wasp Sting

Surgical Treatment of Dupuytren's  
choice of incisions

- References:

The early history of contracture of the palmar fascia. Part 1: The origin of the disease: the curse of the MacCrimmons: the hand of benediction: Cline's contracture.

The early history of contracture of the palmar fascia. Part 2: The revolution in Paris: Guillaume Dupuytren: Dupuytren's disease.

Abductor digiti minimi involvement in dupuytren’s contracture of the small finger.

Percutaneous Fasciotomy for Dupuytren's Contracture 

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, October 16, 2013 2:25 pm