Dupuytren’s disease: overview of a common connective tissue disease with a focus on emerging treatment options

History Felix Platter of Switzerland appears to have been the first to document what later came to be called Dupuytren’s disease (DD) in his case report published in 1614 of a stonemason with digital contractures of his ring and little fingers. Unfortunately, he misattributed the deformity to contracture of the flexor tendons so was superseded by later anatomists who correctly delineated the fascial rather than tendinous nature of the contractions [1]. The medical literature has credited the first description of DD to the French military surgeon and anatomist Baron Guillaume Dupuytren (1777–1885) who published an account of his surgery on his coachman in the Lancet in 1834 [2]. However, it was actually the Englishman Henry Cline who, in the year of Dupuytren’s birth, dissected two hands with palmar fascial contractures and first correctly described DD as a disorder of the palmar fascia rather than of the flexor tendons as previously thought [3]. Later, in one of his lectures, Cline suggested DD should be treated by open palmar fasciotomy and, in 1822, one of his eminent students, Sir Astley Cooper, demonstrated that percutaneous aponeurotomy (using a Cooper knife) was also a successful treatment [3]. Dupuytren is known to have visited Cooper in 1826 but did not perform his first operative release of a fascial contracture until 1831 – he published a description of this in 1834 [4]. Irrespective of which of these early surgeons gains credit for discovering the disease, they all (Platter excluded) correctly noted the underlying anatomy of the disease and suggested treatments that are still used today. DD is a benign but progressive fibroproliferative disease of the palmar fascia that often starts with development of fascial nodules, which may progress to the formation of cords along lines of tension within the volar surface of the hand. It may progress distally into affected digits (often entwining the digital neurovascular bundles within spiral fascial cord extensions) and can result in severe, irreversible digital contractures and considerable limitation of hand function [5]. It may present in one or both hands (although not always with symmetrical disease progression) and, although often not thought of as a systemic complaint, is commonly associated with several other fibroproliferative disorders (Garrod’s knuckle pads [6], Peyronie’s disease of the penis [7] and Ledderhose’s disease of the plantar fascia) [1]. Dupuytren’s disease (DD) is a common, fibroproliferative disease of the palmar fascia of unknown pathology. DD blights the hand function of many individuals and yet it remains an unsolved conundrum. Despite clear knowledge of the anatomy of this aggressive disease and an ever-increasing understanding of the underlying pathophysiology, cellular mechanisms and genetic basis for the disease, curative treatment remains elusive. Described in the 18th century, some of the early surgical treatments remain central to management today, with the gold standard treatment continuing to be surgical removal of the diseased tissues. A plethora of nonsurgical and minimally invasive treatments have been tried with variable success; the efficacy and safety profiles of radiotherapy, steroid injection and injectable collagenase Clostridium histolyticum are explored in this article. There is also a broad range of surgical options, including percutaneous needle fasciotomy, limited or extensive fasciectomy, dermofasciectomy, salvage procedures and a variety of techniques to close the skin wound. Additionally, the role of skin grafting and the application of fat injection in DD will be discussed, with explanation of the comparative utility of each. Although a cure remains elusive, modern nonoperative management options are gaining increasing popularity. This review gives a detailed, comparative overview of each of the nonoperative and surgical treatments available to today’s clinician and suggests a treatment algorithm to aid in management and decision-making in DD.