A Hand Surgeon’s Thoughts
The first challenge is learning how to spell this disease. Dupuytren’s contracture has a very strong genetic inheritance. It is rarely seen in individuals who do not have genetic heritage from Northern Europe. I most commonly see this disease in individuals whose descendants came from England, Ireland, Scotland, Scandinavia, northern France and northern Germany. This condition simply turns on at some point in a person’s life and does not appear to have any real relationship to injury, activity level or other factors.
Dupuytren’s contracture is commonly seen by hand specialists in the United States and Europe. The condition causes thickening in the palm and can progress to create flexion contractures of the fingers. When the thickenings do not create contractures or if the contractures are mild, they are usually harmless. Many people live their entire lives with this mild condition that does not progress.
When contractures progress and create functional difficulty, action should be taken. It can be difficult for patients to determine when it is time to intervene, and a consultation with a hand specialist can provide reassurance and education. The traditional treatment has been surgery. Although surgery continues to be done in certain circumstances, many changes have recently occurred that have swung the pendulum of treatment in the direction of non-surgical interventions.
Percutaneous Needle Apponeurotomy
Percutaneous needle apponeurotomy (PNA) has been adopted by many hand surgeons as a treatment for Dupuytren’s contracture. It is a procedure that I regularly perform in the office. Only certain contractures are amenable to this treatment. This involves a brief office-based procedure where local anesthetic is injected into the palm at the most prominent area of the cord. The cord is then sectioned by placing a needle through the skin multiple times to weaken the cord. The finger is then gently manipulated and a distinct pop is felt.
This is a very satisfying procedure in the office, as it produces immediate correction for a large percentage of the deformity. A recent patient on whom I performed the procedure, experienced correction of a 60-degree contracture to less than 10 degrees within seconds. This is a simple and cost-effective procedure with minimal recovery. The hand is sore and bruised for a few days, but the patient can resume normal activity immediately without much restriction. A night splint is worn for a few weeks to stretch the skin. The beauty of the procedure is simplicity, cost-effectiveness and ease of recovery.
The drawback of PNA is the risk of recurrence. The cords can reorganize and reform within a short time. However, the procedure can be repeated successfully and some patients choose this simple method and simply come in for a “tune-up” periodically. At times, the disease can become more complex and no longer amenable to this method. Overall, it is a nice tool in the arsenal of treatment against Dupuytren’s contracture.
Collagenase (Xiaflex®) Injections
The major breakthrough in the last several years in the treatment of Dupuytren’s contracture is the use of collagenase (Xiaflex®). This is a substance that is injected into the Dupuytren’s cord that breaks off the tissue of the cord. It takes just a few minutes to perform the injection in the office. The patient returns a day or two later to the office for manipulation of the cord and in most cases the finger immediately straightens. This method involves some bruising and swelling in the hand but recovery is rapid and the patient is allowed to return to normal activity very quickly. This can offer a great advantage over surgery in the ease of recovery and the simplicity. This cannot be done on the first clinic visit because it has to be approved and ordered for each patient individually. The approval process usually takes 2 to 4 weeks. This method has proven to be highly successful and is now being widely used throughout the United States, and I use it regularly in my office.
Why Choose Collagenase Injection Over PNA?
Unlike the PNA method, there is much less of a chance that the condition will come back in the same place when using the collagenase injection. In other words, the recurrence rates are very low after the finger has been corrected. The development of the collagenase injection has greatly reduced the necessity for surgery for this condition. It can rapidly return patients to normal hand function and greatly improve their quality of life. Like any treatment, there are certain circumstances where the condition is not amenable to any of the less-invasive treatments detailed here. In these cases, although there is a more involved recovery period, surgery is highly successful at correcting the problem.
*hand drawing is from the American Academy Of Orthopedic Surgeons website
Dr. Pater’s recommended links for further education on Duputryen’s contracture: Xiaflex
To set up an appointment with Dr. Pater to discuss your options, call 303-772-1600.
Surgeon: Dr. Timothy Pater
Reason for orthopedic care: Dupytren’s Disease
Rich loves working on his cars, but it became difficult when he developed Dupytren’s Disease.
Dupytren’s disease, also known as Viking’s disease, is a connective tissue disorder. The disease causes thickening in the palm and can progress to create flexion contractures of the fingers. When contractures progress and create functional difficulty, action should be taken.
For Rich, the disease started in his right hand, “It wasn’t particularly painful it was just a nuisance. It was hard to shake people’s hands,” Rich said.
Seven years ago, when Rich was living on the west coast, he decided to have surgery on his right hand to release the tendons. “The surgery fixed the Dupytren’s, kind of. The surgery was very invasive and painful. I was in a wrap for almost a month and then I went to therapy for 3-4 months… The end result was my finger was straight but I couldn’t make a fist very well.”
Rich was frustrated with the surgical procedure and how long the recovery took. Since Dupytren’s isn’t particularly painful he decided to ignore the disease when it started to develop in his left hand.
When Rich went to see his primary care doctor, Dr. Letkomiller, for a routine check-up, she suggested that Rich go see Dr. Pater. “If it was going to be surgery again, I was not at all interested,” Rich said. Nonetheless, Rich went to see Dr. Pater. “I had heard of alternative procedures (to surgery) and Dr. Pater explained all my options… I chose the Xiaflex injection and it was amazing.”
Dr. Pater explains, “The major breakthrough in the last two years in the treatment of Dupuytren’s Disease is the use of Collagenase with the trade name of Xiaflex. This is a substance that is injected into the Dupuytren’s cord that breaks off the tissue of the cord. It takes just a few minutes to perform the injection in the office. The patient returns a day or two later to the office for manipulation of the cord and in most cases the finger immediately straightens. This method involves some bruising and swelling in the hand but recovery is rapid and the patient is allowed to return to normal activity very quickly. This can offer a great advantage over surgery in the ease of recovery and the simplicity.”
Rich couldn’t be more thrilled with Dr. Pater and his recommendation for Xiaflex, “There was no after-pain other than tenderness. I was using my hand like I used to the very next day,” Rich said. By the end of the week Rich was working with wrenches on his car… something he hadn’t been able to do in years.
If Rich had to rate his experiences they would be: Surgery = “-7” – Xiaflex = “just amazing!”
Rich also added, “Dr. Pater is very straight forward and candid. I like that he gave me my options. I’ve already recommended him.”