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Options For Severe Dupuytren Recontracture 2/2

The three traditional treatments for severe recurrent Dupuytren contracture are PIP joint fusion, dermofasciectomy and amputation. These have been reviewed here. The list of alternative approaches is growing, particularly for the most difficult problem of PIP joint recontracture. The problem is that over time, the tendons and ligaments of a bent PIP joint change and these changes keep the joint from straightening even after all of the Dupuytren tissue is removed.

For many years, the traditional surgery to correct a severely contracted PIP joint with Dupuytren disease has been fasciectomy and joint release. With this surgery, Dupuytren tissue is removed from the finger, and if the PIP joint still won’t straighten, the surgeon cuts the tight joint ligaments. That usually allows the joint to straighten more in the operating room. Unfortunately, the gains from joint release are often lost in the months after surgery – frustrating. It took years for the extent of this problem to be appreciated.

These are possible choices to explore for Dupuytren recontracture. They may require some persistence in finding a surgeon willing to take them on because they are both uncommon and technically challenging.

Two stage external fixation and fasciectomy. Tight tissues can be lengthened if they are stretched very gradually. It’s hard to stretch out a bent PIP joint because there’s only so much pressure the skin can take before it’s painful or develops an ulcer from the pressure. A workaround for this is external skeletal fixation, or external fixation. With external fixation, screws or pins are put into bones on each side of the problem area and are left sticking out of the skin. These pins can be used like joysticks to pull on the bones without pulling on the skin. This approach has been used for many years for the big bones of the arms and legs, but is trickier in the little bones of the fingers. The technology for external fixation for Dupuytren contracture was pioneered by Messina and refined by Agee A comparison of fasciectomy with PIP joint release versus two stage contracture correction with external fixation and fasciectomy found better contracture correction with the two stage approach:

Fasciectomy and barrier material implant. One theory is that the skin itself somehow provokes severe Dupuytren biology and recontracture. Dermofasciectomy addresses this by replacing the skin with skin graft. Another option is to put some type of barrier between the skin and the underlying tissues. Early experience with this approach are encouraging:

Middle phalangectomy. After PIP fusion, the PIP joint is stiff, but there’s no perfect single angle for this joint. The end joint still moves, but it’s in the wrong location to make a good grip. Also, PIP fusion for a severe contracture shortens the finger sometimes the length of one of the finger bones. An alternative which sounds strange but may work better than PIP fusion is an operation called middle phalangectomy.  With this new procedure, the middle finger bone is removed, and the remaining halves of the 2 finger joints are combined to make one joint at the location of the prior PIP joint. Like PIP fusion, this shortens the finger. Like PIP fusion, it converts a 3-joint finger to a 2-joint finger, but the joint which remains is in the PIP location, which makes it more natural to grip a hammer or golf club.

Prolonged continuous splinting. This is a long shot but doesn’t involve surgery. Although splinting is not as effective as external fixation, that doesn’t mean that it never works. One publication reported an average 15 degree contracture improvement with splinting and therapy alone At the 2015 International Conference on Dupuytren disease, Degreef reported an an average of over 30 degrees of contracture improvement with splinting alone. Her protocol involved splinting 20 hours a day for 3 months. The long term results are not yet known, but it confirms anecdotal experience that others have had.

Ultimately, the answer for severe recontracture must be prevention, not salvage. This is the goal of the Dupuytren Foundation’s International Dupuytren Data Bank Research project.