Dupuytren’s Disease: What do I do about it?

He’s old enough to know what’s right but young enough not to choose it.

from the song “New World Man” by Rush

Once a patient has been told they have Dupuytren’s disease the next question is what to do about it.  In general patients that develop cords will get a contracturewhich causes the finger to bend will need some form of treatment.  It’s usually best to wait until a contracture has progressed a little bit before considering treatment since mild contractures really don’t get in the way of hand function.  A joint usually has to contract about 30 to 40 degrees before it starts getting in the way and that’s the point that most patients start to think about getting something done.

In the past the most common treatment was excision of the cord by surgery.  While this sounds fairly simple, in reality I always found this to be one of the hardest surgeries I did.  The cord, although well defined, was often tightly connected to the skin so it required a great deal of skill and patience to remove the cord from the skin.  What was even more difficult, however, was the fact that the cords often wrapped around the nerves and arteries to the finger, and it was very difficult to free the cord from the nerves and arteries.  Although I’ve never cut a nerve during a Dupuytren’s surgery I think it is something that could happen even with a careful and skilled surgeon.  The care after surgery is also very difficult since the extensive surgery required to excise the cord caused a good deal of swelling.  Many patients require therapy and the recovery from the surgery often takes several months.  That being said, surgery is usually very successful in removing the dupuytren’s tissue and straightening out the finger.  Dupuytren’s can come back after surgery and the surgery for recurrent disease is even more difficult than the original surgery.

In order to avoid many of the difficulties of surgery several surgeons tried something a little less invasive.  Instead of removing the entire cord they began cutting the cord with a sharp needle under local anesthesia.  In medical terms this is known as a needle aponeurotomy.  Many hand surgeons utilize this technique and have good results with the procedure.  It can be done in the office under local anesthesia and is much less invasive than the surgery that is done to remove the cord.  In addition recovery is much quicker than with surgery.  Personally I have never done this procedure because of my fear of damaging a nerve or artery with the needle.  It also seems that the recurrence rate after needle aponeurotomy is pretty high, which is to be expected since the dupuytren’s tissue causing the cord is not removed.  I think this is a good choice for patients as long as the treating physician has a lot of experience with the technique.  Needle aponeurotomy makes me a little nervous so I don’t do it, but I understand the reasons people choose to have this done.

A third option has now been available for the past 6 years.  Several physicians worked to develop a drug which , when injected into the cord, could cause the cord to start to unravel and allow the cord to be separated, allowing the finger to be straightened.  The cords are made out of a material called collagen, and the medicine is a protein that eats up or lyses the collagen.  In medical terms the medicine is called a collagenase, and the medicine we used is known as Xiaflex.  Xiaflex was introduced in 2010 and this has been my first choice for the treatment of symptomatic cords since that time.  The medicine is first injected into the cord, and then at a point 24 to 72 hours after the injection the finger is straightened out, which causes the cord to tear and disrupt.  The Xiaflex continues to work even after the cord is straightened, so that in a lot of cases the dupuytren’s tissue eventually dissolves.  The results from Xiaflex treatment seem to be similar to surgery.  The biggest downside is the cost of the drug.  Most of the time insurance covers most of the cost but patients can be stuck with a significant bill.  My office has a lot of experience in dealing with Xiaflex so we can usually get a pretty good idea of the financial aspects involved in the treatment.

In summary, in the past surgery was about your only choice to remove dupuytren’s disease and straighten out a crooked finger.  Less invasive techniques such as needle aponuerotomy and collagenase injection (Xiaflex) have been developed so that patients now have a choice of treatments that they can discuss with their physician and decide which one suites them best.

 

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