Dupuytren's disease: controversial aspects of management

Surgical literature is replete with descriptions of Dupuytren's contracture and the various operations which surgeons have utilized to correct contractures of the palmar fascia. All that is worthy of presentation now are the unknown factors or frontiers of our knowledge. Etiology and control of major complications such as pain, joint stiffness, and recurrence are the frontiers which seem most intriguing to the author. The first step in scientific exploration of these areas is to form a hypothesis which takes into account all of the known factors. In this treatise, the author has stated a hypothesis for each of the frontiers. One hypothesis is that genetic predisposition for selective hyperkinetic collagen metabolism in the palm may be a biological counterpart to the condition found in transversalis fascia in patients with direct inguinal hernia. A hypothesis for pain syndromes is based upon general visceral afferent impulses striking a preconditioned central tract or sensitized central receptor. Joint stiffness has been attributed to the protracted release of polypeptides which change the electrical charge on crystalline protein and result in binding of water which then leads to secondary remodeling of joint structures. Recurrence or persistence of Dupuytren's contracture has been considered to be the result of a persistent inductive phenomenon by cells in the deepest layer of the dermis. Brief arguments supporting these hypotheses as being more tenable now than most others have been presented. For the most part such deductions have been based primarily upon the argument that no other hypothesis presently before us takes into account all of the available data or clinical observations, meager as they may be. Prejudice for surgical biology as a means of enlightenment, intuition, and, at times, empirical reasoning has been admitted in an attempt to stimulate imagination. The rest is left to the reader.