Treatment Options for Dupuytren’s Disease

Comparison of Treatments for Dupuytren’s Contracture

  Open Surgery Min. Invasive Surgery(needle aponeurotomy, NA) Enzyme Injection(Xiaflex™, collagenase)
Goal of treatment Remove the contracted tissue by conventional surgery through incisions in palm and finger(s) Mechanically disrupt contracted cord(s) with a hypodermic needle and multiple skin punctures Inject an enzyme to chemically dissolve a contracted cord
Treatment location Outpatient operating room Office exam room Office exam room
Anesthesia IV twilight sedation Local injections in palm Local injection in palm
Time needed for treatment 30-60 minute surgery, 3-5 follow-up office visits, possible hand therapy 15-30 minute surgery, 0-1 follow-up office visits 15 minutes on injection day, 45 minutes next day
Skin incision Yes; sutures required No; rather multiple needle perforations, no sutures No; Single needle puncture
Bandage after treatment Forearm, palm, affected finger(s), rigid Palm and affected finger(s), soft Palm and affected finger, soft
Bandage duration 2+ weeks 1-3 days 1 day
Number of follow-up office visits 2-4 over 6-8 weeks None required 1, the day after injection
Need for hand therapy Probably: 2 visits/week for 6-8 weeks Probably not Probably not
Time before resuming self-care activities Same day Same day Same day
Time before resuming desk and keyboard activities 2-3 weeks 1-3 days 1-3 days
Time before getting hand thoroughly wet 7-10 days 1-4 days 12 hours
Time before resuming forceful grip such as golf, hammers 6-8 weeks 1 week 1 week
Likely duration of benefit from treatment 5-20 years 1-5 years Probably more than NA & less than open surgery
Treat multiple fingers on same day? Yes Yes No; next finger could be treated a month later
Adjacent tissue at highest risk for injury; frequency of complications Nerve; 1-2% Nerve; 1-2% Tendon, 1-2%
Risk of the treatment causing lasting stiffness in untreated fingers 20% 1% 1%
Main advantage(s) Thorough treatment of multiple joints at one time; usually quite durable Office procedure; Multiple joints treated at one time Office procedure
Main disadvantage(s) Prolonged convalescence, risk of untreated fingers becoming stiff Will likely need more treatment later May need > 1 injection per contracted joint; small risk of serious allergic reaction
This table was prepared by Dr. Roy Meals of UCLA to provide a preliminary understanding of the treatments available for Dupuytren’s contracture. Get your questions answered, and have the treatment planned specifically for you, taking into consideration your general health, functional needs, and pattern of Dupuytren’s disease.

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Needle Aponeurotomy (office-based procedure)

Needle Aponeurotomy is a minimally invasive alternative to surgery for Dupuytren’s disease. This procedure can be performed in an office setting and has a very short recovery time, allowing almost immediate return to full activity. It is also less expensive than surgery and does not require a lengthy course of hand therapy after treatment. A nighttime brace is often used for about 3 months to maintain the correction.

Revived in France over 20 years ago, the techniques of Needle Aponeurotomy were brought to the U.S. in 2003 by Dr. Charles Eaton of Jupiter, FL, who has trained many physicians currently practicing the procedure in the U.S., including Dr. Andy Nelson.

LESS INVASIVE = LESS PAINFUL

Needle Aponeurotomy, or percutaneous fasciotomy, is a minimally invasive – and therefore less painful – procedure that uses a needle to pierce the skin & underlying cords of the palm and finger. The small needle is used to release the cord much the same as a knife cuts a rope.

Traditional surgery, or fasciectomy, involves cutting out tissue from beneath the skin and cutting the contracting cords with a scalpel.

LOCAL ANESTHESIA

Open Surgery requires the patient to go under general anesthesia; Needle Aponeurotomy requires only a local anesthetic.

LESS SCARRING

A large incision is made during surgery, requiring several stitches to close and can lead to significant scarring. The small puncture wounds made during a Needle Aponeurotomy require only a few small band-aids and cause little, if any, scarring.

SHORT RECOVERY TIME

The full healing and recovery time for Open Surgery can be lengthy – 6 weeks to 3-4 months to heal and have the scar tissue soften with 2-3 months of hand therapy.

Recovery from Needle Aponeurotomy takes 2-7 days, allowing an almost immediate return to activity. The same day of the procedure, patients are able to engage in normal activities like eating, dressing, going to the bathroom and showering. Generally no hand therapy is required although a night splint is often prescribed.

NA dressing

LESS EXPENSIVE

Costs for surgery are significantly higher due to surgical center and anesthesiologist fees, higher insurance co-pays (insurance specific) as well as a 2 to 3 month course of hand therapy. None of these fees apply to Needle Aponeurotomy.

***Dupuytren’s Disease is currently NOT curable and will recur to some level.

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Xiaflex™ collagenase injection (office-based procedure)

The tendons that move our fingers and the Dupuytren’s cords that cause our fingers to contract are made of collagen. Xiaflex™ is the brand name of collagenase, an enzyme that dissolves collagen.

During the procedure, Xiaflex is injected into the center of a Dupuytren’s cord. The hand is bandaged until you return the following day, allowing the enzyme to work overnight dissolving the cord. The next day at our office your finger is manipulated into a straighter position.

Xiaflex Injection.jpg

There is usually mild to moderate pain after the injection with some swelling and bruising. The manipulation is performed after numbing up the area.

Each affected finger could require up to three (3) injections; studies indicate the average is 1.5 injections per finger. Not all fingers can be made straight. If there is not a full correction after the first injection, additional injections may be considered; there is a 30 day minimum waiting period between injections.

Xiaflex™ was made available in the US in March 2010 after being studied in over 1,000 patients in the US and Australia.

The current cost of Xiaflex™ is several thousand dollars per injection, so it is important to confirm your insurance benefits before undergoing this procedure.

Xiaflex™ requires special handling and refrigeration. Once it is prepared for your procedure it may NOT be stored or reused.

***Dupuytren’s Disease is currently NOT curable and will recur to some level.

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Open Surgery (formal surgical procedure)

Surgery is performed in an operating room with formal anesthesia such as an arm block or general anesthesia. An incision is made over the course of the finger and into the palm to reveal the Dupuytrens material. A scalpel is used to cut and remove the Dupuytren’s cords and nodules. Depending on the severity of the contracture or bend, there can be risks of permanent nerve and blood vessel injury that is higher than other techniques.

Approximately 10 days later the stitches are removed and therapy begins. Therapy is patient specific but can last several months. A night splint is often used.

The recovery is often 6 or more weeks.

***Dupuytren’s Disease is currently NOT curable and will recur to some level.

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Radiotherapy (performed by a radiation specialist for early disease without contracture)

Radiotherapy, or radiation therapy, is most effective in the very early stage of Dupuytren’s disease before the fingers begin contracting into the palm. Typically, radiotherapy affects the nodules and cords in an effort to prevent contracture of the fingers. This treatment is most popular in Germany and Austria, where it is considered to be the most effective way to stop Dupuytren’s in an early stage and possibly avoid later surgery.

Nodules and cords are irradiated with electrons or with x-rays that do not penetrate deeply into the body. This is typically done over five consecutive days, applying an efficient dose of mild radiation each day. After a six week break, the treatment is repeated. The specific treatment will be prescribed and laid out by the radiation specialist.

One of the difficulties of radiotherapy is that few people consult their doctor in the very early stage of Dupuytren's, when radiation treatment is most beneficial. Another problem is that radiotherapy has not gained widespread use in the USA because it is not popularly known as a means to treat Dupuytren's disease.

There is a general concern about cancer resulting from high dose x-ray treatments but the risk depends on the dose and energy of the x-rays, as well as the irradiated parts of the body themselves. German Centers have received statements that the increased probability of acquiring cancer as a result of radiotherapy of Dupuytren’s is negligible, but patients should consult with their doctor(s) before taking any risks.

Electron/E-Beam


X-Ray


Picture provided by H. Seegenschmiedt, Strahlenzentrum Hamburg Nord, Germany.
Copyright International Dupuytren Society

***Dupuytren’s Disease is currently NOT curable and will recur to some level.

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