Dupuytren’s disease is an autosomal dominant disorder with variable episomal rates and is influenced by environmental factors.
With advances in the fields of molecular biology and genetics, it is now possible to shed light on the biological events that play an important role in the development of nodules and the progression of bundles. Growth and maturation factors may be key factors in the prevention and treatment of this disease. Lian Zhizhen, Department of Restoration and Reconstruction Surgery, Wuping County Hospital
Surgery is the main treatment for this disease.
The key to successful surgery is a thorough understanding of the management of normal and abnormal anatomy and vital structures.
Definition
In hand pathology, Dupuytren’s contracture is the most typical feature of the disease and its diagnosis is rarely in doubt.
Anatomically, fibrous tissue-forming fascia exists beneath the skin of the palmar surface of the hand and is prominently present in the palm, finger and finger web spaces. These fasciae continue to be connected to each other, to the dermis and to the deeper fasciae by fibrous fasciae. All these fasciae are considered as “bands” and are named as palmar tendon membrane, ligaments or other different names. These fibers are called “bundles” when they are hyperplastic, nodular or contracted [1]. The presence of these “bundles” gives Dupuytren’s contracture its characteristic appearance.
Dupuytren’s contracture is defined according to the above-mentioned pathological manifestations.
Dupuytren’s disease is progressive and aggressive in nature. The palmar ulnar side of the hand is the most common site of occurrence, with occasional invasion of the radial side. Other heterotopic lesions occur in less than 3% of cases and commonly include.
Garrod’s nodes or knuckle pads on the dorsal side of the proximal interphalangeal joint are also common.
Metatarsal fascial contracture of the foot (Ledderhose contracture)
Buck’s fascia contracture of the penis (Peyronie’s disease)
Epidemiology
Dupuytren’s disease is generally considered to be autosomal dominant, with varying rates of ectopics reported in the literature [2]. However, less than 10% of patients with Dupuytren’s disease have a positive family history. Some evidence emphasizes the influence of environmental factors on the development of Dupuytren’s disease.
The true prevalence of Dupuytren is unknown and varies with ethnicity. As part of a large sample screening, Mikkelsen [3] surveyed 16,000 Norwegian urban residents and found a prevalence of 9.4% in men and 2.8% in women. yost et al. surveyed over 5,000 inpatients in New York City and found an overall prevalence of 4.8%.
The age factor has a clear relevance, with Dupuytren’s disease rarely seen in people under 40 years of age, and the age of onset mostly seen between 40 and 65 years.
A large number of studies have focused on the factors of onset. Three factors have received the most attention: alcoholism or liver disease, epilepsy and its therapeutic drugs, and diabetes mellitus. Other pathologically relevant issues studied include smoking, HIV infection, local trauma and work injury (the cause considered when first proposed by Dupuytren), and hyperlipidemia.
Pathogenesis
As the pathogenesis of Dupuytren’s disease continues to be understood, and as the fields of molecular biology and genetics mature, it is now possible to shed light on the biological events that play a crucial role in the development of nodules and the progression of bundles.
Clinical presentation
The lesions are superficially organized and clearly located in the subdermis of the skin or spread to the dermis. The nodules in Dupuytren’s disease do not show signs of tendon slippage, a feature that can be recognized on clinical examination and is significantly different from the flexor tendon nodules in stenosing tenosynovitis. The diagnosis is rarely in doubt by appearance, texture, common location, and the usual absence of painful features.
Contracture of the Grapow ligament, a subcutaneous ligament that spans the palmar aspect of the first web space, can limit thumb abduction. The severity of functional limitation of the joint is highly variable following the development of Dupuytren’s contracture lesion, and the progression of the lesion cannot be predicted in advance.
There is no classification system for Dupuytren’s disease. Accurate evaluation of disease severity and prediction of surgical outcome requires a detailed and comprehensive understanding of the pathologic anatomy of the disease and the degree of static contracture.
Ancillary investigations
A thorough history investigation should include.
Lesions of the hands, feet, and penis
Treatment
history of trauma
Family history
Imaging and laboratory tests are rarely needed to help determine this. If a severe flexion contracture deformity is present and a release surgery is planned, x-ray is required to rule out primary joint disease. Electrophysiological examination is performed if the diagnosis is easily confused with some neurological disorders of the hand deformity or if muscle atrophy cannot be explained.
Treatment
The treatment of Dupuytren’s disease is “binary”, where the binary refers to observation and surgery, which are performed simultaneously. To date, there is no effective pharmacological treatment. Many authors have previously reported non-surgical treatments, including radiotherapy and topical medications (steroids, collagenase, interferon, etc.), but ultimately these methods have not been validated and are not considered to be clinically useful.
Surgical strategy
The surgical strategy is straightforward: excision of the diseased tissue and release of the secondary contracture in all directions. The simplicity of the surgical strategy does not mean that the surgery is simple; surgery for Dupuytren’s disease is challenging and includes an adequate preoperative evaluation, extensive separation and protection of the vascular nerves during surgery, complete excision of the lesion, and reasonable reconstruction of the tissue defect.
First, clarifying the location and form of the diseased tissue and its impact on the neurovascularity is a prerequisite for proper surgery. The first step of surgery is the correct treatment of the skin and selection of the incision. Accurate determination of the extent of the contracture and adequate anticipation of the tissue defect formed after contracture release are the most important components of a challenging surgery.
The surgical incision for single-finger or single-row Dupuytren’s contracture can be made with the Brunner incision. This incision can be modified depending on the requirements for contracture release, and Thomas J. Graham and Thomas R. Hunt in Orthopaedics recommend a transverse V-Y advancement of the Brunner incision for fingers with 30° to 60° of flexion contracture. For contractures beyond 60°, skin defects after complete release are difficult to resolve directly with simple incisional reshaping methods and may require the use of the McCash palmar opening technique and various skin grafting techniques.The McCash technique keeps the palmar wound open and heals by a second-stage healing approach is difficult to accept, but it is indeed safe and effective [4], [5]. Immediate coverage of the palmar skin defect is usually recommended and is thought to reduce contracture recurrence, so skin grafts are more often used. However, the fact is that the risk-benefit ratio of skin grafting is not always good due to donor area complications, discomfort due to skin mismatch, etc.
There are two special incisions that are recommended, the first one when the Dupuytren lesion is concentrated on the ulnar side of the little finger and the second one when multiple fingers are involved.