Controversy: Splinting for Dupuytren Contracture

Fig. 44.1

A dorsal hand-based thermoplastic splint

Fig. 44.2

A volar hand-based thermoplastic splint

44.2.3 The Role of Postoperative Splinting

Some surgeons routinely advise postoperative splinting after fasciectomy and dermofasciectomy. This has also filtered down to some patients post percutaneous needle fasciotomy (PNF). The training brochure for collagenase Clostridium histolyticum injections (Pfizer publication 2011) recommends night splinting for up to 4 months as this was used in the clinical development programme. However, three randomised trials indicate that extension splinting is not necessary after surgery.

Jerosch-Herold et al. (2011) conducted a pragmatic, randomised, multicentre trial of 154 patients undergoing fasciectomy or dermofasciectomy in the UK. Randomisation took place after surgery with 77 patients receiving normal hand therapy and 77 receiving hand therapy plus a volar hand-based thermoplastic night splint to be worn for 6 months and complete a splint diary. Tension was set using the Evans “no tension” principle. Ethically, as it was unknown if a splint might be useful, if a finger recontracted by 15° at the PIP and 20° at the MCP joint beyond the first postoperative measurement, a night splint could be applied. 13 of 77 patients in the non-splinting group recontracted beyond these parameters and subsequently received a splint. There was no difference between the groups at 3, 6 and 12 months in satisfaction, active flexion/extension and the DASH score (Disability of the Arm, Shoulder and Hand) on an intention to treat analysis. 84 % of the splint group and 77 % of the crossover patients used the splint for 50 % or more of the nights. The conclusion is that the routine use of a night splint conferred no benefit but could be used if a contracture starts to recur.

Collis et al. (2013) used similar methodology in NZ with 26 patients receiving therapy and a dorsal hand-based night extension splint and 30 patients receiving hand therapy alone after fasciectomy. 3 patients in the splint group received a splint due to recontracture. At 3 months follow-up, there was no difference in DASH scores, total active extension and flexion between groups.

Kemler et al. (2012) randomised patients to hand therapy with a splint or therapy alone. The inclusion criteria targeted a Dupuytren Disease subtype that is generally thought of as more difficult to successfully treat – PIP joint contracture of greater than 30° undergoing fasciectomy. The study protocol did not allow for crossover if recontracture occurred; the splint was dorsal hand or forearm based and worn full time for 4 weeks and then night only for 2 months. One year after surgery, the splint group had a mean reduction of 21° in PIPJ flexion contracture and the hand therapy alone group 29° (a better result but not statistically different).

There seems little benefit to the routine addition of a night splint to normal hand therapy practice.

44.2.4 Splinting as a Nonoperative Treatment

Laboratory-based studies which grow Dupuytren fibroblasts in a collagen matrix show increased contraction in response to a tensile load (Bisson et al. 2004). Such applied forces are short-lived (over hours/few days), and there is no evidence that such a model can translate to practical splinting tips although it does raise some interesting questions. Two small studies have investigated the use of a splint as a nonoperative treatment. Ball and Nanchahal (2002) looked at 6 patients using a volar-based night splint with 6–24 months follow-up. Only 2 patients were able to comply with a splint regime over 2 years but did show improvement of their MCPJ contractures (12 to 0 and 30 to 22°).

Larocerie-Salgado and Davidson (2011) asked 13 patients (19 digits) to wear a volar hand-based thermoplastic splint at night and perform passive stretch/friction massage. One patient left the study and underwent surgery. PIPJ extension in the remaining 12 patients improved on average by 14.6° (pre-splint range 15–60°) at mean follow-up of 12.6 months in 13 of 19 digits. 2 digits showed no difference and were deemed to have stabilised. The average age was 69.4 years. The later effect on the Dupuytren contracture if splinting were to cease is unknown.

Acknowledgement and Conflict of Interest Declaration The author is grateful for the help of Debbie Larson for hand therapy advice and manuscript review. The author was the local principal investigator for the POINT X open-label 3B collagenase trial. He received payment into his research account from Pfizer for recruitment of 10 patients as per protocol. The account is administered by the Norfolk and Norwich University Hospital NHS Trust.

44.3 Splinting Is Beneficial

Wolfgang Wach⁶

(6)

International Dupuytren Society, Westerbuchberg 60b, 83236 Übersee, Germany

44.3.1 Introduction

Wearing a night splint for some period of time is frequently suggested after treating Dupuytren contracture with PNF (percutaneous needle fasciotomy), collagenase injection or surgery. Clear and undisputable evidence of the efficiency of these recommendations is still missing. Nevertheless there is some evidence encouraging further investigations and using splints. This chapter is addressing the use of static night splints for longer-term night splinting (months or years), not short-time splinting (days), immediately after treatment (Clare et al 2004).

44.3.2 Anecdotal Evidence

Anecdotal evidence can be found, for example, in the forum of the International Dupuytren Society (IDS 2015) and in reports from members of the IDS. Here are a few examples:

The patient Stefan H, having had 8 surgeries and 1 PNF, reports that night splinting was required after surgery of recurrence or when the contracture had persisted over a longer period of time (years). Also after PNF he considers night splinting a necessity to avoid quick recurrence.

Barry N had 15 surgeries, including 4 dermofasciectomies, and 3 PNFs. He reports that he needed no splinting after surgery, provided the finger became straight, but found splinting after PNF beneficial to avoid or postpone recurrence.

Rainer Z had 2 PNFs. He wore a night splint for 3 months and now wears it for a week whenever he feels that a finger starts contracting. So far he has succeeded in maintaining his PNF results over 8 and 3 years, respectively.

John C had 2 PNFs. After the first PNF, he wore no night splint and after the next PNF, which was carried out by another doctor, he reports: “She prescribed an additional procedure, that being keeping a splint on my hand for 90 days while I slept. That has helped immeasurably”.

The patient OJ had 1 PNF. He wore a night splint for 3 years and maintained the PNF result. He then lost his splint when moving and didn’t care getting a new one. He experienced recurrence to the initial state within a year.

The author himself had partial fasciectomy (20 deg MCP of the ring finger) 15 years ago and did not wear a splint after surgery. The postoperative treatment was simple bandaging until the wound had healed and some physiotherapy. After 15 years his hand is still fully functional and shows no signs of recurrence. But he also had collagenase injection (45 deg PIP of the little finger). The extension deficit was not completely eliminated, about 20 deg remained. He was able to maintain this result for 14 months whilst wearing a night splint regularly. He then stopped splinting because he felt that the splinted hand eventually became stiffer, not only in the morning but also during the day. He had recurrence to the original amount of contracture within 4 months.

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