Dupuytren’s Contracture (including Xiaflex)
In 1831, a famous French surgeon, Baron Guillaume Dupuytren, described a contracture of the tissue beneath the skin of the palm which now bears his name. It can be severe enough to cause deformity in the hand and interfere with normal use. It is a gradually advancing disease, and can cause progressively more curling up of the fingers.
No one understands the cause of this disease. People often wonder if injury can cause it. Scientific studies have shown that it probably can not.
Dupuytren’s disease tends to run in families. It does not follow, however, that if a patient’s father or mother had it he is necessarily going to get it. It is particularly common among Caucasians, especially those of Northern European descent. It is rare in other races, though it can occur.
The disease usually begins with small lumps in the palm of the hand, at the base of the ring or small fingers. Discomfort may be associated with these lumps, particularly if they are in locations which are subject to repeated injury in a patient’s job, but usually, the disease is painless.
Lumps can progress to cords, which extend from the palm into the fingers. Cords cause bending of the joints of the hand which can progress to severe flexion deformities. This can occur slowly or rapidly, and it is difficult to predict the rate at which it will occur. Sometimes progression may stop. It can start again unexpectedly. The disease may progress to the point that everyday and work activities become difficult or impossible.
The skin can be intimately involved in the process, and sometimes removal of some of the skin is necessary for surgical treatment. The tendons which control the fingers are not involved, though the nerves and blood vessels to the fingers can be intertwined with the diseased fascia.
Until recently, the only treatment for Dupuytren’s disease was surgical removal of the diseased tissue. However, within the last few years, two additional treatments have become available.
Needle aponeurotomy is a procedure done in the office under local anesthetic (simple lidocaine or similar anesthetic injected into the skin). Using a fine needle, the surgeon carefully and methodically penetrates the skin and cuts the Dupuytren’s diseased tissue. For appropriate patients, there need no longer be the fear of a large open surgical procedure with the necessary lengthy recovery time. If your condition is appropriate for needle aponeurotomy, the procedure is done during a standard office visit. While there may be some bruising associated with the procedure, the overall recovery time is substantially shortened.
This procedure was pioneered in France, and within the last few years has become available at a select few centers in the United States.
More recently, a drug has been introduced that has been investigated for two decades. A number of researchers, including Drs. Hurst and Badalamente from the State University of New York at Stony Brook, have long sought to be able to treat Dupuytren’s disease with medication. Finally, this hope has been realized. (see New York Times stories about this treatment)
Sold under the trade name of Xiaflex, the drug (collagenase clostridium histolyticum) is now available through specifically qualified physicians. Treatment of Dupuytren’s disease can now often be accomplished by one to three injections of this medication, followed within 48 hours by a gentle manipulation.
Treatment may be recommended when the fingers begin to bend or if the hand can not be placed flat on a table. Rapid progression which interferes with normal hand function may warrant early treatment.
Despite treatment of the diseased fascia, whether by surgery, needle aponeurotomy or collagenase clostridium histolyticum injection (Xiaflex), disease may occasionally return. Treatment may not completely cure the disease. The goal of treatment is to retain normal hand function.
Surgical treatment involves making usually zig-zag shaped incisions in the palm to remove the diseased fascia. Most often, block anesthesia is used, in which the arm is completely numbed but the patient is not put completely to sleep. This is the safest for most patients, and comfortable both during and after surgery. Most often patients will be able to go home the day of surgery, though it may be prudent, in some cases, to spend a night in the hospital. Sometimes part or all of the wound may be left open intentionally by the surgeon, depending on the condition of the patient’s remaining skin. Often, small plastic tubes or drains will be inserted, which will be removed one to two days after surgery. The post- operative dressing applied by your surgeon is designed to immobilize the hand and provide compression to the wounds.
Post-operative therapy is sometimes useful to obtaining a good result. The length of therapy is much shorter if treatment is by needle aponeurotomy or collagenase clostridium histolyticum (Xiaflex) injection. In some cases, therapy may be unnecessary. A number of different plastic splints may have to be worn after treatment to attain full motion and maintain the contracture- free state of the fingers. These may have to be worn for up to one year. Depending upon the treatment, return to manual activity may be as soon as a week for needle aponeurotomy or collagenase clostridium histolyticum (Xiaflex), or considerably longer if surgery is needed
Several complications can occur from the treatment of this disease. Needle aponeurotomy can rarely cause damage to tendons or nerves. Collagenase clostridium histolyticum (Xiaflex) injections may be associated with an allergic reaction, and normal tissues in the hand may be adversely affected or may even rupture. If surgery is performed, incisions will remain tender for quite some time. Bleeding or infection can occur and slow recovery. Joint stiffness may occur. Nerves or blood vessels to the fingers may occasionally be damaged. Full mobility may never be regained. Recurrence is always possible.
Considerable progress has been made in the treatment of Dupuytren’s disease. While surgery was the only option until quite recently, advances in pharmacology and other techniques have made alternate treatments available. We can evaluate your condition at Virginia Hand Center and make recommendations for the most effective form of treatment for Dupuytren’s disease.