Associated lesions: Knuckle pads and Dupuytren’s diasthesis

Dupuytren’s contracture and Knuckle pads at the hand, Ledderhose at the foot and Lapeyronie’s disease form Dupuytren’s diathesis28.

Described by Garrod, Knuckle pads are the dorsal form of Dupuytren’s disease (see Figure 5). They are particularly common in Northern Europe. They are well tolerated but, when voluminous, can limit the flexion of interphalangial joints or become an aesthetic issue. Intra-nodular injection of a corticosteroid brings dramatic reduction27. Disinfection is followed by subcutaneous injection inside the nodule with a 25G 0,5x16mm needle adapted on a 2ml syringe. The corticosteroid should not be fluorinated because of the risks of cutaneous atrophy. We use prednisolone acetate 2.5% (Hydrocortancyl®). The injection is rarely painful and can be performed without anaesthesia. Complications are exceptional, and septic risks the same as with usual corticosteroid injections. One or two injections at two-week intervals reduce the size of the nodule in two weeks after a dyschromic phase, of which the patient should be forewarned. However these inconveniences are negligible compared with the poor results of surgery in knuckle pads, which leads to frequent cheloid scars.

Ledderhose disease presents as a unique fibrous nodule or cord located on the sole of the feet, very similar in aspect to a Dupuytren nodule. Not as frequent as Dupuytren’s contracture (2- 3 % association), it has the particularity of occuring earlier in age, often during the second or third decade. Contraction of the toes never complicates the evolution but a conflict can arise with the shoe, the patient complaining of a feeling of “pebble in the shoe” when walking or running.  Surgical treatment should be avoided because of a major risk of painful scar as well as reoccurence on the scar. Injection of 2.5ml of prednisolone acetate with 2.5ml of lidocaine followed by aponeurotomy with the same needle (25G 0,5x16mm) is a good alternative. In our experience night application during five weeks of local imiquimod (Aldara® cream) brings a rate of 30% of satisfactory results by softening of the cord.

In La Peyronie’s disease (1% association to Dupuytren’s) fibrosis locates on the tunica albuginea of the penis. The diagnosis is easely made in presence of Dupuytren’s contracture; the patient describing an aquiered angulation of his penis in erection. Three injections of prednisolone acetate, strictly in the nodule, at 3 week intervals and associated to 1mg colchicine daily during 3 months results in 50% of good results.

Conclusions:
Dupuytren’s contracture is a frequent affection and can lead to progressive disability. Surgical treatment is aimed at advanced stages29, with several weeks of convalescence30 and important risks of complications and reoccurrence. In trained medical hands, needle aponeurotomy is a safe technique that can be used at earlier stages bringing immediate results. In case of recurrence, treatment can be repeated. Therefore needle aponeurotomy emerges as a first-line treatment.