Therapy of Dupuytren's disease
Synonyms
Dupuytren's contracture; Fibromatosis of the palmar fascia, Dupuytren's disease
English: Dupuytren's contracture
General / Introduction
Depending on the stage of the disease, Dupuytren's disease can treated in different ways become. Unfortunately, the usual, conservative measures such as physiotherapy are ineffective, so that surgical therapy is often resorted to. In the following the individual therapy options, their application, advantages, disadvantages and chances of success are presented.
Stages of Dupuytren's disease
Dupuytren's disease is staged according to the stretching deficit. The degree of flexion contracture of all joints of an affected finger is added.
This gives rise to four different stages of Dupuytren's disease:
- Stage I: 0 to 45 °
- Stage II: 45 - 90 °
- Stage III: 90 - 135 °
- Stage IV:> 136 °
In order to be able to completely escape from therapy, one should prevent Dupuytren's disease. For this, in turn, knowledge of the causes is relevant. To do this, read: Causes of Dupuytren's Disease
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In our very economic world in particular, there is too little time to thoroughly grasp the complex diseases of orthopedics and thus initiate targeted treatment.
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Hand surgery = operation of the Dupuytren's muscle
To this day, hand surgery is the most common form of therapy for Dupuytren's disease. She serves the Restoration of hand function and can as only therapy in all stages the disease can be used. However, the operation is one relatively large intervention, so that this type of therapy is usually only used in the event of severe functional impairment. To restore functionality, an attempt is made to restore the Free hand tendons from all connective tissue strands and knots.
In the total fasciotomy will that the affected tissue and the aponeurosis of the palm of the hand are generously removed. Since this is a very large procedure with the risk of a complete loss of function of the hand, this technique is now used in the treatment of Dupuytren's disease only rarely applied.
The currently most frequently used technology is the partial fasciactomy. The affected tissue and possibly parts of the aponeurosis are removed. However, the functionality of the hand can be retained.
Under the Nodal Fasciotomy one understands one Removal of the knots and some of the strands. The aponeurosis remains, however. Depending on the stage of the disease of Dupuytren's disease, the strands are not completely removed but only separated.
The segmental aponeurectomy refers to a very minor intervention that only removes individual segments of the cord. The goal here is Interruption of the strands and thus the Cancellation of the contracture. In some cases this will remove the contracture forever. However, some of the strands can be re-formed.
The biggest intervention in Dupuytren's disease is Dermofasciectomy. Here are the affected tissues and the overlying skin is generously removed, and the skin through one the body's own skin graft replaced. If this is completely successful, a recurrence of the disease can be prevented in most cases. However, this is an extensive procedure that requires a high risk of infection holds and one long healing time needed. If the procedure is successful, the hand can usually be used fully again and the fingers can be fully stretched again.
Duration for a long time a sharp curvature of the fingers, it is possible that only a partial stretch can be achieved. The reason for this is the adaptation of the finger tendons to the curvature position. Nevertheless, one can significantly better functionality can be achieved.
In some cases, following surgery for Dupuytren's disease, a Aftercare recommended. However, their benefit has not been fully established, so there are no specific recommendations for follow-up treatment. However, it is recommended to discuss the follow-up treatment plan with the operating surgeon and contact one for follow-up treatment Dupuytren's disease specialized physiotherapists to turn.
Even after an operation it is possible that the disease Dupuytren's disease occurs again. This depends on the type of surgery and how it is performed. However, other risk factors such as the location of the contracture (thumb or little finger involved) and the male gender are also associated with a higher risk of recurrence.
Needle fasciotomy (percutaneous needle fasciotomy = PNF)
In contrast to the hand surgical procedure, the Needle fasciotomy a minimally invasive procedure with a fast healing time and short post-treatment time.
In this procedure, the connective tissue strands are weakened by needle sticks to the point that they can be manually stretched and torn. In most cases, this method is used to treat Dupuytren's disease outpatient with a light local anesthesia carried out.
The advantage of this procedure is one very little scarring on the skin, as it is only punctured by small needles, and a very short healing time. Often the hand is Functional again after a few days. Besides, the therapy is only little painful and can be applied repeatedly in the event of a recurrence. The needle fasciotomy is usually performed in the Initial stages used as soon as the first signs of a stretch deficit appear.
If an operation is not possible for other reasons, the needle fasciotomy can also be performed in the Stage IV bring a success. Since the contractures are very pronounced at this stage, it is often not possible to fully restore the hand function. However, in many cases a significant improvement in the situation can be achieved. In general, the The recurrence rate is higher with this form of therapy than with the surgical form of therapy, the small intervention and the fast and uncomplicated healing time however, are an important aspect of the needle fasciotomy.
This form of therapy can also be used applied repeatedly become. To minimize the risk of recurrence, it is recommended to wear a night splint for several months after the procedure. This keeps the fingers in an extended position in order to avoid flexion contracture. How long and whether the splint has to be worn varies from person to person and should be discussed with the attending physician.
Enzyme injection with the collagenase
The connective tissue strands that are responsible for the contractures consist mainly of collagen. In the meantime, an enzyme has been developed, collagenase, which breaks down these strands.
This enzyme is injected into the Dupuytren's cord and has to act for about a day. Then the strands are torn manually as in a needle fasciotomy. Since the development of this enzyme is still relatively new, no long-term studies to assess the therapeutic results of Dupuytren's disease are available.
In Germany, the drug was withdrawn from the market for cost reasons, as it does not yet have any clear advantages over other therapies for Dupuytren's disease.
In other countries, the collagenase is still used and is considered to be promising. There are also no relevant studies to date with regard to possible side effects. The most common acute adverse reactions reported were local injection site allergic reactions. These appeared as edema, dark, blister-shaped bulges on the skin, bruises and bleeding. In general, these symptoms were only mild and subsided after one to two weeks in the studies. In addition, itching and pain in the hand were often observed.
radiotherapy
Radiation therapy is a form of therapy for Dupuytren's disease that is used in Initial stages stop the progression of the disease can. The aim is to disturb the ability of the fibroblasts, cells that are responsible for the formation of the nodes and strands to divide. This reduces or even prevents the further formation of knots and strands.
Dupuytren's disease usually remains be up to date with the irradiation situation. For this reason, radiation therapy is only useful in the initial stages, because she cannot stretch fingers that have already been bent. The affected area of the palm of the hand is penetrated with a safety margin of 0.5 to 2 cm superficial soft X-rays irradiated. In order to protect the unaffected areas from the radiation, they are protected with a lead cover.
Different concepts for irradiation have proven themselves. The individual doses are between 2-4 Gy (Gray), and the total dose is between 20 and 40 Gy. If the total dose is 30 Gray, irradiation is carried out with 3 Gray each on five consecutive days in the first cycle. After a treatment break of 6 to 12 weeks, another series of treatments follows the same concept, so that a total dose of 30 Gray is achieved after the treatment. 3 months and 1 year after the last treatment should respectively Follow-up examinations respectively. Attention is paid not only to changes and regression of the nodes and strands, but also to possible changes in the adjacent areas, which could be an indication of radiation damage. A increased risk of cancer is always associated with radiation. However, according to studies, it appears negligibly small to be when the part of the body not to be irradiated is well protected.
Overall, radiation therapy exhibits in its early stages very good results and can prevent Dupuytren's disease from getting worse for many years in most cases. Because of this, it's a great way to get one Postpone surgery. Since radiation is particularly effective in the early stages, when the first lumps appear, patients should consult their doctor at an early stage.
Exercises
During the exercises for Dupuytren's disease, care must be taken that not only the affected hand is used, but that both hands perform the exercises equally. Depending on how severe or advanced the disease is, the most helpful method can be selected from various methods.
In addition to these exercises, there are other physical therapy treatments for Dupuytren's disease.
