Dupuytren's Disease:
Minimally Invasive versus Open Treatment
Dr. Glickel discusses Dupuytren’s Disease in the New York Times. To read the article click here.
Introduction:
Dupuytren’s Disease is an abnormality of the connective tissue in the palm which can result in contractures of the fingers. Dupuytren’s is a genetic disorder which means it is inherited from parents. The pattern of inheritance is called an autosomal dominant with variable penetrance which means that a person can carry the gene for Dupuytren’s but not show any of the manifestations of the disease. Other people who carry the gene develop thickening of the connective tissue in the palm which can result in nodules or lumps in the palm and/or fingers and longitudinal bands of tissue which can cause the fingers to bend and be unable to fully straighten. Some patients develop contractures in one finger and others develop them in multiple fingers. Mild contractures can be well tolerated. However, moderate
to severe contractures can interfere with hand function. Things as simple as putting on gloves and reaching into a pocket can be awkward or difficult.
Indications for Treatment:
Having Dupuytren’s Disease is not necessarily an indication to treat it. If a person has a nodule or cord but no limitation in motion, there is no indication to do anything. However, if one or more fingers flex toward the palm, more than a few degrees then consideration should be given to treating the contracture in order to straighten the affected fingers.
Treatment Options:
Fasciectomy:
There are currently three principal forms of treatment for Dupuytren’s Disease. The
traditional way to address the contractures of Dupuytren’s is called partial palmar and digital fasciectomy which simply means removing the contracted tissue from part of the palm and from the affected fingers. The procedure is done through one or more incisions over the affected tissue which is carefully removed. Afterwards, the hand is placed in a splint for a few days and then the patient begins a program of therapy to decrease swelling, care for the wounds and regain motion. The therapy can take anywhere from a few weeks to several months.
Clostridial Collagenase (Xiaflex):
An alternative to fasciectomy is one of two forms of minimally invasive treatment. Xiaflex or clostridial collagenase is an enzyme that digests collagen which is one of the principal constituents of connective tissue. It was approved by the FDA as a form of treatment within the past year. The treatment involves injecting Xiaflex into the thickened cords of Dupuytren’s on one day and then manually rupturing the cord the following day. The procedure is fairly expensive and may or may not be covered by insurance. It can be painful during the injection and for a day or two afterward. It has also been reported to cause enlargement of lymph nodes in the armpit which resolves after a few days. This technique has been shown to be effective.
Needle Aponeurotomy:
The other technique of treatment which is an alternative to traditional fasciectomy is called needle aponeurotomy. The procedure can be done in the operating room with light sedation or in the office under just local anesthesia. The surgeon marks several points along the affected, thickened cord. Beginning at the base of the cord in the palm, the surgeon places a small needle through the skin and cuts the cord with the tip of the needle.
After doing this at several points, the surgeon manually straightens the involved finger. The advantage of this technique over fasciectomy is that the patient is able to straighten and bend the finger(s) almost immediately and there is little or no therapy required. I had done fasciectomy for many years, and consider the early results that I have seen with needle aponeurotomy to have revolutionized my approach to treating Dupuytren’s Disease. Most, importantly, patients have been very pleased.