Current Management of Dupuytren’s Disease
A Surgeon’s Perspective
Around 1832 Baron Guillaume Dupuytren described the clinical and anatomic features of Dupuytren’s Disease (DD) as well as the treatment appropriate for his time. The patient was operated on in a seated position with the hand elevated. No tourniquet was used, and no anesthetic, as we now understand it, was available. Dupuytren stood behind the patient because in this position it is less easy for the patient to withdraw the arm, and he performed a simple release of the contracted fascia, which was probably all that was possible under the circumstances. By advocating the simple division of cords (fasciotomy) over the excision of the diseased tissue (fasciectomy) later described and advocated by later surgeons, Dupuytren began the controversy that still exists today regarding the treatment of this disease.
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.