Dupuytren’s Disease is characterized by the development of fibromatous cords and nodules in the fibrofatty layer beneath the skin along the longitudinally oriented ligamentous strands. In certain individuals, these cords can begin to contract and draw the fingers down into the palm. The various treatment methods that have evolved over the years serve to correct this deformity. Unfortunately for the people affected by this disease as well as those who treat it, there is a tendency for the condition to recur despite what modality is used. The long term recurrence rate is usually reported to be greater than 50%.

Open fasciectomy has long been an accepted treatment for DD. It involves excising the diseased tissue in the palm and fingers to correct the contractures. The extent of dissection required and the amount of tissue excised is also a topic that is up to debate, but all of the described procedures involve large incisions and long recovery times. Out of all the currently used treatments, open fasciectomy maintains the lowest reported recurrence rate and greatest reported degree of correction, but this must be balanced out by a higher risk of complications (17%) including pain, nerve or arterial injuries, hematomas, wound infections, hand stiffness and RSD. The lengthy recovery and rehabilitation period along with time missed from work are also major deterrents for today’s patients. However, open fasciectomy remains my treatment of choice for those with severe disease.

In light of the many downsides of open surgery along with the high recurrence rate, a lot of effort has been put into developing better nonoperative and less invasive techniques to treat this disease. These techniques are not meant to “cure” the disease, but rather improve the function of the hand with a low rate of complications and a speedy recovery time. Percutaneous needle aponeurotomy is one of these techniques that has gained popularity in recent years. It involves the use of an 18-25 gauge needle to cut the digital and palmar cords at multiple levels. This can generally be done in the office under local anesthesia. ROM can be initiated immediately following the procedure and bandages are removed the next day. I also have my patients wear an extension splint at night for a few months after the procedure to maintain their correction. There is usually no formal therapy needed. The main complications associated with this procedure are nerve and flexor tendon injuries, but these are relatively rare. Most of the published studies indicate that this procedure works very well in correcting mild and moderate contractures, but that the long term recurrence rate is going to be higher (65%) than that for open treatment. Overall, patients are usually very satisfied with the procedure and are pleased with the amount of correction they are able to achieve.

The newest kid on the block for the treatment of DD is the enzymatic degredation of the diseased cords using a collagenase injection. Although attempts at enzymatic degredation have been tried in the past, this is the first one to gain FDA approval. The new drug, named Xiaflex, gained FDA approval in February of 2010 and has been heavily marketed over the past several months. The collagenase is derived from Clostridium histolyticum and acts to hydrolyze the diseased collagen fibers and allow for passive extension exercises to disrupt them. The process involves having the patient come to the office for the injection of a single cord for a single joint and then having them come back to the office 24 hours later for finger extension procedures to rupture the cord if it has not already spontaneously ruptured. The process may be repeated up to 3 times per cord at 4 week intervals to achieve the final result. There is generally no hand therapy recommended for this as well other than the fabrication of an extension splint to be worn at night for 4 months to maintain extension. The most common complications reported in the trials were injection site edema, swelling, erythema, contusion and pain. There were very few reports of tendon rupture (0.3%) and no reports of nerve damage. The phase 2 trial results were promising and showed that up to 77% of MP joints and 40% of PIP joints achieved a reduction to 0-5% after up to 3 injections. However, a recent study on the 8 year follow up of patients treated with the collagenase injections reported a recurrence rate of 67% for the MP joints and 100% for the PIP joints. Unfortunately, there were only 8 patients that completed the study. Also, it should be noted that the average degree of MP joint recurrent contracture was only 22 degrees, which is below many surgeon’s threshold for recommending surgical management of their disease. Overall, despite the recurrences, 88% of patients were pleased with their results and would pursue further injections for recurrence or progression. The main disadvantage of Xiaflex, as I see it, is the cost. The cost of a single injection is $3,200.00. That means $3,200.00 per joint, per administration. So, if a patient had contractures of both the MP joints and PIP joints of 2 fingers and would require 3 injections per joint, the total cost of the medication alone would be $38,400.00. The company also requires the physician to purchase the product and then try to get reimbursement later. I have heard reports that insurance companies and even Medicare have been reimbursing physicians for the medication, but many of these issues are still being hashed out. Also, considering that Medicare will only reimburse $53 to perform an injection, there is not a big monetary incentive for physicians to start using it. With all of the uncertainty in the economy and the great healthcare debate still raging, it is hard to rationalize spending that many healthcare dollars for a temporary improvement that has not proven better than some of the other treatments.

It is clear that there is no magic bullet for treating Dupuytren’s Disease and there will continue to be debate regarding the optimal treatment for these patients. There are advantages and disadvantages to each of the above mentioned treatments and I believe that the choice of treatment should be made by the patient after they are given as much information as possible about each of them. The most important discussion I have with patients before initiating any treatment deals with what their expectations are or should be regarding their results and making sure they completely understand what would be required of them to get there. Each and every patient has their own unique life circumstances and because of this, I do not have any strict criteria for recommending one treatment over another. However, I usually tend to continue with observation until either the patient is unable to lay their hand down flat on a table or they are extremely concerned about the cosmetic appearance of their hand. As a surgeon, I am constantly striving to offer the best treatment possible for my patients and I am glad that there are multiple options to choose from. There are many patients in our fast paced society that do not or cannot take the time off or deal with the discomfort associated with an invasive surgery. They would rather live with their disease than do anything about it. In these situations, collagenase injections or percutaneous needle aponeurotomy are excellent choices. The results may not be as near normal or long lasting than they would get from an open surgery, but their hands are markedly improved and they do not have to spend 3 months recovering. I have found that many do not expect their hands are going to be perfect and are content with the knowledge that they may need future treatments. As long as the procedure matches the expectations of the patient, there is a good chance for success.

Do your fingers feel numb or tingly when you perform strenuous activities with your hands? Do you wake up in the middle of the night because your hands feel like they are asleep and you need to shake them out to get the feeling back in them? If you answered yes to these questions, you may be experiencing symptoms of carpal tunnel syndrome (CTS).

Carpal tunnel syndrome is the most common nerve disorder affecting 4 to 10 million people each year and contributing to a great deal of time missed from work due to its sometimes debilitating symptoms. It is caused by compression of the median nerve as it passes through the wrist in a narrow passageway about the size of your thumb called the carpal tunnel. The median nerve travels from your neck down the arm and through this tunnel to provide sensation to the thumb, index, middle and half of the ring finger. It also sends impulses to the muscles in the palm that control certain thumb motions. This tunnel is bound by bones on 3 sides and a tight ligament on the 4th side giving it a limited amount of space. Passing through this tunnel along with the median nerve are 9 tendons that function to flex the fingers and the thumb. Anything that causes inflammation or swelling of any of these structures within this confined space compresses the median nerve. The result may be pain, weakness, or numbness in the hand and wrist, radiating up the arm.

The symptoms of CTS usually start gradually, with frequent burning, tingling, or itching numbness in the palm of the hand and the fingers, especially the thumb, index and middle fingers. These symptoms are aggravated by activities that put the wrist in a flexed or extended position for a prolonged period of time such as holding the steering wheel while driving or talking on the phone. Pain is another common symptom and can sometimes radiate up into the shoulder. Patients frequently experience these symptoms at night when they are awakened from sleep and feel like they need to shake out their hands to try and get the feeling back into them. As symptoms worsen, people typically begin to have difficulty grasping objects and notice a decrease in their grip strength. They also may begin to notice some atrophy of the thumb muscles that can occur in the late stages of the disease due to some permanent nerve damage.

Carpal tunnel syndrome is often the result of a combination of factors that increase pressure on the median nerve and tendons in the carpal tunnel, rather than a problem with the nerve itself. CTS may be found in patients who are pregnant, overweight or have various medical conditions, including thyroid disease, diabetes or arthritis, or injuries such as wrist fractures or sprains. Whether repetitive work activities cause carpal tunnel syndrome is still controversial, but it is thought that some strenuous repetitive hand activities, especially those involving vibratory motion, can worsen the symptoms. Just as frequently, the syndrome occurs on its own. It is thought that there is likely a genetic predisposition in most patients who suffer from CTS, meaning they simply have a smaller carpal tunnel.

Early diagnosis and treatment of carpal tunnel syndrome are important to avoid permanent damage to the median nerve. The diagnosis should be made by a physician based on an accurate description of the patient’s symptoms along with a detailed physical examination. A physical examination of the hands, arms, shoulders, and neck can help determine if the patient’s complaints are related to daily activities or to an underlying disorder and can rule out other painful conditions that mimic carpal tunnel syndrome. Routine laboratory tests may also be performed to help identify other medical conditions known to cause CTS. Often it is necessary to confirm the diagnosis by use of electrodiagnostic tests. In a nerve conduction study, electrodes are placed on the hand and wrist. Small electric shocks are applied and the speed with which nerves transmit impulses is measured. In electromyography, a fine needle is inserted into a muscle; electrical activity viewed on a screen can determine the severity of damage to the median nerve. Ultrasound imaging can show impaired movement of the median nerve. Magnetic resonance imaging (MRI) can show the anatomy of the wrist but to date has not been especially useful in diagnosing carpal tunnel syndrome.

Treatments for carpal tunnel syndrome should begin as early as possible, under a doctor’s direction. Underlying causes such as diabetes or arthritis should be treated first. Initial treatment generally involves resting the affected hand and wrist for at least 2 weeks, avoiding activities that may worsen symptoms, and immobilizing the wrist in a splint to avoid further damage from twisting or bending. If there is inflammation, applying cool packs can help reduce swelling. Anti-inflammatory medications such as ibuprofen or naproxen are commonly used to help relieve some of the symptoms by further reducing the inflammation. Steroids are sometimes injected directly into the carpal tunnel to provide some temporary relief of symptoms. Stretching and strengthening exercises can be helpful in people whose symptoms have abated. Most experts would agree that if symptoms persist after 6 months of these conservative measures, surgery should be recommended to relieve the pressure on the median nerve.

Surgery for carpal tunnel syndrome involves transecting the tight ligament that forms the roof of the tunnel. This relieves the pressure on the median nerve and increases the volume inside the carpal tunnel by around 25%. There are 2 basic techniques used today. The traditional open technique involves making a 1-2 inch incision in the wrist directly over the ligament and then cutting the ligament. The endoscopic technique involves making a smaller incision proximal to the ligament, inserting a small camera into the carpal tunnel to view the bottom surface of the ligament and then cutting it under direct vision. The advantage to the endoscopic technique is that it creates less scaring and has been shown to allow patients to return to their normal activities sooner than with the open technique. Both procedures can be done on an outpatient basis with minimal or no sedation along with some local anesthesia. The choice of which procedure should be performed should be made by the surgeon based on a variety of factors. Although symptoms may be relieved immediately after the surgery, most patients will experience some tenderness in the palm that will take a couple of months to completely resolve. Sometimes, a short course of supervised hand therapy will be ordered to help with the recovery process. Most patients are able to return to their normal activities within 2 weeks of surgery, but the length of recovery can vary based on how long the patient has had symptoms and how badly the median nerve was damaged.